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~ APPLICATION 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 Snit 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 PAu']blic Health Services. f Jab Address 1, f ' e, City Lot Size/Acreage Owner's Name - �� Address Phone Contractor Address 7t License N43 Phone " i TYPE OF WELL/PUMP: - NEW WELL ❑ ` __WELL REPLACEMENT T1 DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION 0 'SYSTEM REPAIR 0 OTHER 0 Monitoring well C7 , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l_} Industrial ❑ Open Bottom .0 Manteca Dia. of Well Excavation Dia. of Well Casing (a Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ -- Specifications I.i Public Cl Other ❑ Delta Depth of Grout Seal F� *-Type of Grout ------ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed byt , Repair Work Done 0 Type of Pump H,P. _i State Work Done i Well Destruction D Well Diameter Sealing Material & Depth 1 Depth Filler Material & Depth . TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIWADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is J available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: —I-- Number of bedrooms + 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. D Type/Mfg Capacity No. Compartments 71 PKG. TREATMENT PLT, ❑ —Method of Disposal } Distance to nearest: Well a Foundation ^ Propeny Line j LEACHING LINE C1 No. & Length of lines Toial'lengihlsize Wo FILTER BED (;l Distance to nearest: Well �> Foundation 0-6 ___ Property Line j2 e� SEEPAGE PITS 1'1 pth Size_ keq- Number J SUMPS Dist nce_to nearest: Well _ Foundation �! Property.Line DISPOSAL PONDS Cl 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 - I. . _: - ;_ —, 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 bf 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 issusd,�'!'ahall dr�ploy persons subject to workman's compensa- tion laws of California." The applicant must cap for al uired inspeetio s. Complete drawing on rev rseside Signed X� I 11 r rf r�-wQ Title: - r ' " Date: OR DEPARTMENT,. S PUE,ONLY Applica ' n Accepted by Date Arr�e�a� �ut Additions! Cammenu: d( � �� r Applicant- Return all copies ta: _San Joaquin County Public Health Servic , � �J Z I�. I�, `,- � Environmental Health Permit Services �w 445 N San Joaquin, P O Box 2009, Stkn, CA 9520.116770 FEEAMOUNT DIE NT R MOUITTED RE IVED DATE PERMIT'N0. INFO ��./// CASH . EK 1]-21 INEV.r i e 51 1V /, L. EK 11.10