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"7 APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SIZA9 + ENVIRONMENTAL HEALTH D I V I S I O A�nO# [ 445 N SAN JOAQUIN, PHONE (209)468 3 2" P O BOX 2009, STOCKTON, CA 952 QAC # r PERMIT EXPIRES I YEAR FROM DATE I - -- ' # (Complete in Triplicate) aS / S Colo,0IL S7-. Application Is hereby made.to Sao 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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address�' A0t3 L St City Lam' Lot Size/Acreage ChanlLes /1/1d�l-�4;5- yg- ((-o-77 Owner Name d ��" r'!/�� Address / /V L .'" �a Phone Lno I S s 71 ��nc L' ��& 2— t 7y zny8 . Contracor T SS li Rddres ,� License IVO. Phone s� r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service Well ❑ I, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE f� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f_I Domestic/Private ❑ Grave) Pack ❑ Tracy Type of Casing_ Specifications 1'I Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx.f0epth l I Eastern Surface Seui Installed by € Repair Work Done U Type of Pump H.P. State Work Done _ Ii Well,Destruction X Well jpmetei +r Sealing Material i Depth R _ �pM ,4+� co,.l7��TiarJrI.;L r Filler Material i Depth ( R TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) t"• Installation will serve: Residence Commercial_ Other }; Number of living units: Number of bedrooms Q Character of soil to a depth of 3 feet:i Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line PAYME LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED Cl distance to nearest: Well Foundation Property Line € SAN JOAQUIN COUNT SEEPAGE PITS 11 Depth Sire Number PUBLI ES 4 TAI pl HEALTH I51ON SUMPS LI Distance to nearest: Well Foundation Property Line 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 Csllfornio." The applicsm all for all r d inspection . ompiete drawing on reverse side. Signed X Title: Date: T t FOR DEPARTMENT USE ONLY i Application Accepted by Date Areal Pit or Grout Inspection fIDate Final Inspection by Dets�� Additional Comments: i Appl3can�t - Return all copies to: San Joaquin County Public Health Services (D Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE E AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'N0. EH 14-20 rR1;V,1/NSI v "DV 1.00