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APDL 16T I ON FOR PSRId I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSPED (Complete in Triplicate) A Application is hereby made to SaaJoaquin County for a permit to construct and/or install the vork herein described. This application is a in compliancefvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County blic H ltbjSerMces. Job Address City 2tlLot Size/Acreage � f Owner's e P Na `` Ad rens Phone Co ra o �(� /Gt.f[ABre 90dZJZ4ense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ F DESTRUCTION 0 Out of Service Weii 0 r PUMP INSTALLATIO4� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C] 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 C7 dustrial ❑ Open Bottom ID Manteca Dia- of Welt Excavation Dia. of Well Casing omeatie/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications l'1 Public 1:7 Other 1-1 Delta epth of Grout Seal Type of Grout I I iniflation —.Approx.:Oe 1 I stern r ,5u'rfaee Seal Installed by Repair Work Done U Type of Pu H.P. ( ' State Work Do Well Destruction ❑ Well Dia ter ;1::-g2 Sealing Material i Depth Depth Coy Filler Material i Depth ��,(� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public "or is ` 1 available within 200 feet.) Installation will serve: Residence--a� 't Commerciat— Other Number of living units: Number of bedrooms - �- Character of roll to a depth o�f 3 fee; r f •�` Water table depth SEPTIC TANK. O,-Typs/Mfg �`�' Capacity* �^ ~ No. Compartments PKG. TREATMENT PILT.G1 k " "f x � - �ti Method of Disposal Distance to nearer;:;..,_,,.Well--- - -.-.--.--,.Foundation aProperty Line LEACHING LINE ��Ll No. & Length of lines `7otallength/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS. i I I Depth f Size Number SUMPS J . LI Distance to rwarest: Well- v Foundation Property Line DISPOSAL PONDS.1-,'O ._' 1 hirabyAesrtify 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 Sen_Joaquin Count ) + Home owner or licensed'agent'a 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." Contractors hiring or sub-contracting signature certifies the following: "1 WON the in the performance of the work for which this permit is iss ed,I shall employ persons subject to workman's compenss- tion laws of rnia." Thea t t call to ins tions. Complete drawing on r rse sig / Title• Date: FOR DEPARTMENT USE ONLY - Application Accepted by — __ _ Date Area DL- f q� Pit or Grout Inspection byDate Final Inspection by Date Additional Comments; Applicant Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services z r 445 N San-Joaquin, P O Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE i AMOUNT REMITTED CK ECEIVED BY DATE PERMIT NO. . EM14.2 (REV.i i M 5 EH tb2e