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r. APPLICATION r ' f - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES l ENVIRONMENTAL HEALTH DIVISION f 445 N SAN JOAQUIN, PHONE (209)46$--3420 i P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services.- Job ervices.Job Address City SL��+ Lot Size/Acreage Owner's Named ��/�� Address Phone 3 Contractor TT S .�Address fW_ �= License No.2!E�Vl Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT - DESTRUCTION CI Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well 0 11 .3 `1„ DISTANCE TO NEAREST: SEPTIC TANK -� SEWENES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITSISUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C� Industrial ❑ Open Bottom ❑,Manteca Dia. of Well Excavation Dia. of Well Casing �\ [:ItDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications - k I"1Public iLO s Other f 1 Dena' Depth of Grout Seal Type of Grout I I�Irrigalion _Approx. Depth I I Eastern Surface Seal installed by Repair Work Done L7 T i Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Well Material b Depth i tt Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I' DESTRUCTION € I INo septic system permitted if public sewer{is e a€ailable within 200 feet.l Installation will serve: Residence 4 Commercial— Other # a., Number of living units: _4e-- Number of bedrooms- 15- i - t �haracter of soil to a depth of 3 feet: It Water table depth o SEPTIC TANK Type/Mfg e'P VC _0 �4�I�Capacity 'No-Compartments f` PKG. TREATMENT PLT. ❑ Method of Disposal o- F Distance to nearest: Well —d-0—it—Foundation /-09 Property Line 1 moi' LEACHING LINE Cl No. & Length of lines Total Iengthfsize All X d FIOTER BED ❑ Distance to nearest: Well Foundation - ' Progeny Line SEEPAGE PITS 110 Depth Sixe- � Number _ SUMPS LI Distance to nearest: Well Foundation �A/ Property Line [��' DISPOSAL PONDS ❑ 4 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 p 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 Jhall not amptoy 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'fovwhich this permit is issued,I shall employ persona subject to workman's compensa- tioA!! laws of California." a f Th8'alicant must all for all r {' c pp squired inspections. Complete drawt� on reverse side, Signed X Title:. -�Lrfl11-t Date: FOR DEPARTMENT_ USE ONLY Ap�lication Accepted by C�' � Date �� n Area 0 ` rA 40 Pit or Grout Inspection by Data Final Inspection by -Date Ad hional Comments: `- F Applicant - Return all copies to: San.Joaquin County Public .Health Services Environmental;Health Permit/Services 445 N San Joaquin, P Q Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. • EM 17.21 f[REV,t i n 51 fi/ 'f ©� �f _ 6-3 EH[1•Ie [t/ / [O