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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County ,pEPuublic Health Services. %s�..� ` Job Address �7" 10 - S N 5�q =AJ �/&_/� City_ Lot Size/Acreage ,..,/Owner's Name L �;-+�1N � cf-e-COf Address `r�� Phone - �- (ContractorAddress License No, Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER D Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing El Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications V] Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth f I Eastern Surface Sem Installed by Q 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 I REPAIR IADDITION ,DESTRUCTION INo septic system permitted if public sewer is available within 200 feet,I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms aW3 Vt-61d�a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg C�o f Capacity A d0 No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well/DD Found atiorf__e� Properly Line LEACHING LINE K No. B Length of lines Total length/size XT- FILTER BED n Distance to nearest: Wed-C-A&._ Foundatiort� /�r do"rProperty Line r (� SEEPAGE PITS �fj� Depth �� Size Number -__-A- D SUMPS LI Distance to nearest: Well Foundation a/::C_ I 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, 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 persona subject to workman's compensa- tion laws of California." . The applicant must tali for ail required ins ions. Complete drawing on reverse side. , K ~� X Signed Title: _ .-_ Date: F DEPARTMENT USE ONLY Application Accepted by r. _ r ��,,, .e Date AreaQ� -�_2- Pit or Grout Inspection by D e Final Enspection by Date L7 j Additional Comments: �' ' , L4 f Applicant - Return all copies to: San Joaquin County ublic Health Services ot( '� 40 �� Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 CK IEEE AMOUC�JNc�/T1T DUE AMOUNT REMIT-TED CASH RECEIVED BY DATE �p 193- PERNO- Em EM It�IAEy,r i n SJ I/ / Y I AA J1-, 1 0 \J jJ