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_ F I APPLICATION ! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ' Ir PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comlete in. Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. city csr4 Lot Size/Acreage rd0'X/�� Job Address A, At.& 9 i Owner's Name Address a? Phone i Contractor�.�- � fp�-r Address y&0,6 A,� Lcl�v_A✓ � License No. �4��.1'_Phone Ilf TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ out of Service Well ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �p r-1 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I'1 Public i-1 Other r'1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by o Repair Work pone CJ Type of Pump _ H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth 31) Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION X DESTRUCTION ()CINo septic system permitted if public sewer is V n available within 200 feet) J installation will serve: Residence X Commercial_ Other Ayr fy,jv o'ev, TW,0yl! Number of living units: _ZL Number of bedrooms Character of soil to a depth of 3 feel: C.14 U Water table depth o SEPTIC TANK a Type/Mfg P40r irr- c_acc" Capacity AA20-0 No. Compartments PKG. TREATMENT PLT.❑ ;I � Method of Disposal I Distance to nearest: Well + - Foundation _'_ Property Line W _ V i LEACHING LINE >t No. & Length of lines _ Z- Total length/size P '- 2 X 49 FILTER BED ❑ Distance to nearest: Well _ Foundation. /d ___ Property Line /d SEEPAGE PITS 5( Depth tlSire rl 1? Number SUMPS LI Distance to nearest: Well W Foundation �1``� Property Line r F✓- ,®tl�� DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican st call for all req d inspection . Complete drawing on reverse side. Title: Date: 6 Z0-9-� F Signed - F DEPARTMENT USE ONLY 9 c Application Accepted by l Date - ` Area S i Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ! Environmental Health Permit:/Services 445 N San Joaquin, P 0 Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. INFO �,✓7LE . EH 13-24(A riwsi EH 14.16 ;i