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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 16ep P 0 BOX 2009, STOCKTON, CA 95201 ��'1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDVV III (Complete in Triplicate) Application is hereby rade 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. /r�� f t,ff 2b City Lot Size/Acreage _GO Joh Address X r l 4 Owner's Name Address [ [�O �+`,!+�2-1� Phone Q 3 Contractor Address License No.gSG(41 Phone YPE OF WELL/PUMP: NEW WELL 11Cl WELL REPLACEMENT , DESTRUCTION ❑ Out of Service well C7 PUMP INSTALLATION C1SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER-WELL- - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ) r � e- n Industrial ❑ Open Bottom C1Manteca Dia. of Welt Excavation Dia. of Well Casing �1 L7 Tracy Type of Casing^ Specifications P Domestic/Private ❑ Gravel Pack i'1 Public i Cl Other f-1 Delta Depth of Grout Seal Type of Grout 11 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 13Type of Pump H.P. —_ State Work Done1. Well Destruction ❑, Well Diameter Sealing Material i Depth Depth Filler Material i Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted it public sewer is available within 200 feet.l a g• r � 3 Installation will serve:t Residence— Commercial— Other Number of living units: Number of bedrooms 7:) c ' Character of sail to a depth of 3 feet: Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ; Y PKG. TREATMENT PLT. ❑ Method of Disposal [ Distance to nearest: Well Foundation Property Line ' i - I a - LEACHING LINE r ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line �- 3 � SEEPAGE PITS 1 1 Depth Size Number E SUMPS t LI Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS t ❑ / I hereby certify that I hove 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 truing or sub-contracting signature y 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." a applicant must call for all required inspections. Complete drawing on reverse side. �^ 1 igned r Title: �Y.., Date: Ft QEPARTMENT USE ONLY i f Application Accepted by,,. Date. iP 5*a ,_1 Aread)ll(..4� x.12ilka Pit or Grout Inspection by,_ y —Date�. Final Inspection byDate �•� , ' Additional Comments: f Applicant - Return all copies to: San Joaqulu County Public Health Services ny . - - _tEnvironmentai Health permit/Se?r"Aces"' 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. y INFO EH 13-24IREv.1rHei` EH 14.20 J L r �/