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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for s permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San osquin County Public Health Services. J�! ob Address /u _ City J Lot Size/Acreage Owner's Name Address Phone S- = l kcontraclor CW,N-P10= -- —_Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I,Lng�Monitor WellC DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, P OP. LINA; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications 11 Public l-1 Other ❑ Delta Depth of Grout Seal Type of Grout i I I Irritation — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. — State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 2W feet.) 4 Installation will serve: Residence— Commercial_ Other r Number of living units:- Number of bedrooms V 3 Character of soil to a depth of 3 (eet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' `\ PKG. TREATMENT PLT.0 Method of Disposal v 1 Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/site _ w FILTER BED n Distance to nearest: Well Foundation Property Line ` 8 SEEPAGE PITS 1 ) Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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, 1 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 persona subject to workman's compensa- tion laws of California." The applicant mu call 1g;all required 'nspact' n . Complete drawing on res'd Signed X_,� _� Title: r/ LDate: [[ i FOR EPARTMENT USE ONLY } If Application Accepted by Date �D Area Pit or Grout inspection by Date Final Inspection b Datil��%G Additional Comments: l � _�lM.u�fl�� -►� A^-- I Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EN1 .24tNEV.�iNS) � '� t,7- 15F'' F� `f EH 14'