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a. APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ff P 0 BOX 2009, STOCKTON, CA 95201 vh Y,t S_Fc, l PERMIT E%P I RE S 1 YEAR FROM DATE I S SUED (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. Job Address09 City Z,;tizot Size/Acreage i w � Owner's Name t ` ` Address 13� _62z 1 ,Q�? phone Contractor /YIG�C-L [� .Lr.� -Addres 1' ok License NoJ _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ID DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIONXy SYSTEM REPAIR ❑ OTHER 0 Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — 4m FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications - Oy Cl Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Dep 1 1 Eastern Surlice Sedl Installed by Repair Work Done ❑ Type of Pump H.P. Z � State Work Don —eg Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I i DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ® Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L3 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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." Contractors 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 ap ' t must all for all required ins ctions. Complete drawing on revs a side. Signed X Title: �� _ Date: OR J)EPARTMENT USE ONLY Application Accepted by - Date ,-r -L Area © ` Pit or Grout Inspection by Date Fine Inspection by Dataf] Z 421 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services Yo�- 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO nom�n__ n �//y + EM 13-24(REV.iin51 !J X� / �� 1� EH t•-26 VVV