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APPLICATION, x 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 Ban,Joaquin County for a permit to construct and/or install the Work herein described. This application is made in complianceivith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County/Public Health Services. VJob Address _ / S� 5��_1� /ilL!4 City Lot Size/Acreage f —r-7 I /Owner's Name /�� Address �S—flrC) /Mill „_ , Phon4cyT 1/Contraclof Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION D Out of Service Well ❑ PUMP INSTAILLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PR09LEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private 0Gravel Pack ❑ Tracy Type of Casing_ Specifications C1 Public fa Other I n Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. [,,,ph I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I (Rbseptic system permitted if public sewer is available within 200 feet.)Inst ition moi serve: Residence Commercial_ Other ; Number of i units: Number of bedrooms _, Character of soil to th of 3 feet: Water to SEPTIC TANK. ❑ fg t.___ Capacity , Comportments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We oun Property Line LEACHING LINE Cl No. & Length of lines Total len FILTER BED ❑ Distance to{neares Well Foundation Property Line 1 I j SEEPAGE PITS [ I D Size Number f SUMPS Distance t,'nearest: Well Foundation Property Line I DISPOSAL P ❑ I h 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 Sen 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, f 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, 1 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. Signe Title: Oats: FOR DEPARTMENT USE ONLY I Application Accepted by Date —Z Area -71W -I�= Pit or Grout Inspection by Date Final Inspection by Oets y Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, Box 2009, Stkn, GA 95201FEE f INFO AMO T DUE r AMOUNT REMITTED CK R EIVED BY E PERMIT'N0. t:H 17:16 Imo.„M,r r, EH i4•1a �