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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 a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin Co ty Or finance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. lam" Job Address �f City e cLot Size/Acreage 6 a 011 Owner'a Name Address Z:o ! � phony a F _�� Z Contractor__ i Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial O Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Said installed by Repair Work Done U Type of Pump H.P. State Work Hone Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTIONi.CoNo septic system per�u+etf if public sewer is ��availabie .28f�`ieet,l Installation will serve: Residence Commercial_ Other Number of living units: Number of drooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK , Type/Mfgr, p .� i" No. Compartments PKG. TREATMENT PLT. ❑ �� Method of Disposal der tip�I Distance to nearest: y _ oil C � Property tine LEACHING LINE Cl No. $ Le of lirM 019 Mil I a orfl&0 ddngth/size U- i a lit t Property Line FILTER BED ❑ D' nce tp nearasf: UIT i uffw SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DI AL 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 California." The applicant must cjill for all r i petitions. Complete drawing on reverse side. ! p Si d Title: 2476/rtPL20 __ _ Date: FOR DEPARTMENT USE ONLY � Application ccepted by Date Area Pit or Grout Inspection by Date J Date Final Inspection by Date Additional Comments: 49" 22 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AM NT DUE AMOUNT REMtTTEO CK RECEIVED BY DA E PERMIT•NO. INFO //6�/ Jj ��y// . EM 13.2 1 REV. K S! G�� , &S �r ! 7- EH 11•]e �..JJ