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APPLICATION k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2O09,, STOCKTON, CA 95201 PERMIT E%PIRES 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ye- City CAA4 Lot Size/Acreage Job Address LC; ,L ` T Vj CF '° Phone .r Owner'sName.-Com '` `' Ad re ! 0 40 PLicense No 1phone Coritrattor,,� Address a ' 7YP£ OF WELL REPLACEMENT ❑ DESTRUCTION=:❑ Out of Service Well ❑ WELUPUMP. NEW WELL ❑ Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR C1- OTHER 12 C7 DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom �. ❑ Manteca Dia. of Well Excavation Specifications ' C7 Domestic/Private 0 Gravel Pack _n- Tracy Type of Casing_ 7yof Grout . i'1 Public I:l1Oiher ;� ►; f�lDelta ,Depth a� t�G o>�r Seal Type f l I.Eastern Surface Seal Installed by 11 irrigation Approxi.Depthe e O lip _ , 3 Repi it Work Done U Type of Pump --- ! State Work Done Sealing Material & Depth _V Well Destruction ❑ Well Diameter Depth s Filler Material & Depth TYPE OF SEPTIC WORK; NEW WSTALLATION- rREPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is O available within 200 feet-I installation will serve: Residence 6_/ Commercial; rlaer Number of living units: ar Num bar of bedrooms 1I j Cfiaracter of soil to a depth of 3 feet: Water table depth f SEPTIC TANK [I Type/Mfg Capacity ' No. Compartmentil t I Method of Disposal PKG, TREATMENT PLT.❑ ,., e' - �Uxyfl�.:.: = s'� r F Distance to.nearest: r Well Foundation's Property Line l k 'k I LEACHING LINE No. $ Length of lines " — "M1` ~" T.otal Iengthlsize a FILTER BED n Distance to nearest: s s WeII Foundation Property Line 4 SEEPAGE PITS 11 Depth _Situ Number r .. SUMPS Ul ,;Distance to nearest: ' Well Foundation Property Line jDISPOSAL PONDS O I ' 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 t F rules and regulations of the San Joaquin;County -- ,-w---- -. 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 ior•which this permit'is-ssued, I shall employ persons subject to workman's compensa tion laws of California." 4 tsi The applicant must call t r al eqluirWnspec' ns. Complete drawing on reverse side. r. Signed " Title: 1 - _ Date: FOR DEPARTMENT USE ONLY ....-...,,r-,�,._.......r,...,.-.rte--..-- ._ � --:,�:,�- ..� .,:�:.- --•---• � ..L .. �•S' i .Date Area Application Accepted by Z' Date 6 /6 + Pit or Grout Inspection b Date Pinel Inspection by k �- Applicant Additional Comments: - Return all co ies�, �Jqmy Public Health Services Environmental Health Permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201 r CK FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. ` INFO rf� Q ` . EM 13.24 1REV.I/K%I f YJ l��'!Q EH 14.20 !