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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) s 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. Job Address _ S-6e-_7 S__ Z-7 City �� e_&AJ Lot Size creage Owner's Name S Address Z�C 1oja 1q-, . ., Phone Contractor_-- F t O A5 , 44002> Address .. 7 41, gi7 i -��'-� _License No. _phone S-3g'7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION'❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well DISTANCE 70 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 { �1 Industrial ❑ Open Bottoma O Manteca Dia. of Well Excavation Dia. 9f Well Casing El Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ C] Public Specifications __ Iii Other fl Delta Depth of Grout Seal I I I Irrigation TYPe of Gfut Approx. Depth I I Eastern Surface Seai Installed by Repair Work Done 0 Type of Pump H.p State Work Done Wel! Destruction ❑ Wel! Diameter Sealing Material & Depth ' Depth Filler Material & Depth ` TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION E I (No septic system permitted if public sewer is Installation will serve- ResidenceCommercial available within 200 feet.) _ Other ,t Number of living units: ___L Number of bedrooms ` Character of soil to a depth of 3 feet: IP ' n Water table deptK SEPTIC TANK. 1 PKG. TREATMENT PLT, O Type/Mfg „ �X!S7"YA�e-' Capacity Z® 2 No. Compartments l � « to nearest: Well-AM Foundation Method of Disp - _ Property Line- 16ZL�_ LEACHING LINE No. & Length of tines ! 7•-.-¢a-� Total length/size ` o FILTER BED ❑ Distance to nearest: Well --9-120 Foundation __�•` Property Line SEEPAGE P175 III Depth /21 Size 2 r Z SUMPS �n Number 1X Distance to nearest: Well 3CV,'- Foundation DISPOSAL PONDS p Property tine-3D `•� 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: 1-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 call for all required insPections. Complete drawing on reverse side. Signed X Title: Date: OR D RTM T USE ONLY Application Accepted by �� Date Area Pit or Grout Inspection by Date Final Inspection try Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201 FEE AMOUNT D AMOUNT REMITTED CK INFO RECEIVED 8Y DA�(T'E PERMIT'NO. . EH 13-21(REV.7/N 31 !/ / w/ X • V - � , EH 11-20