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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIONj� � t 445 N SAN JOAQUIN, PHONE (209)468-3420 _ P 0 BOX 20091 STOCKTON, CA 95201 1� PERMIT EXPIRES 1 YEAR FROM DATE ISSUID Q 5- 1 , (Complete in Triplicate) (1 Application is hereby made 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r )Job Address `a f r N City Lot Size/Acreage (4 b S ,t XOwner's Name M r--�S-' M 2:� Address � R` Phone. /Qonlracim Se r Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 12 OTHER 'Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private 0 Gravel Pack Ll Tracy Type of Casing_ Specifications Il Public CZ Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation __-_Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P. -- State Work Done Well Destruction ❑ Wall Diameter Sealing Material A Depth Depth Filler Material 6 Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I OESTRUCTION 'No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial-"OtN r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE C1 Na. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth ` Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the wbrk 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: "l certify that in the pedormance 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 applicant must call for all re wired inspections. Complete drawing on reverse side. -7 XSigned Title: ti Dater XX ' c� �PARTMUSE ONLYApplicatiori,Accepted-by Date __C-� 1�j�,� Area -q-- Pit SPit or Grout Inspection by Date Final Inspection by 9J• � � Date �3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 4545 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUEAMOUNT REMITTED CASH K 4 RECEIVED BY DATE PERMIT'NO.9 EH y j24 tREV.F i w si � Z �� / k65-h ' �kh > 125-0� /