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v 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 j (Complete in Triplicate) I Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application In made in coatpliance with San Joaquin County Ordinance No. 549 and 2$62 and the Rules and Regulations of San Joaquin County Public Health Services. I Job Address City Lot Size/Acreage i 1 � C��.. Owner's Name Address s, Phone Contractor Address_L1 Q. ��i� 'License No.TcP_%LS Phone TYPE OF WEL UMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR Ile OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL-- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O ` n Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing "V V Domestici Private ❑ Gravel Pack7 ❑ Tracy Type of Casing. Specifications W [1 Public Cl Other 171 Delta Depth of Grout Seal Type of Grout O I i Irrigation „ _Approx. Depth, I I Eastern Surface Saul Installed by Repair Work Done d- Type of Pump --- H.P. State Wok one Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material ✓4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION Ik INo septic system permitted if public sewer 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. Co% V11 r� r PKG. TREATMENT PLT;Ll Metho 'o I Distance to nearest: Well Foundation Property Line ENtu LEACHING LINE 0 No. A Length of lines Total length/size wly JOAQU11” .I--FILTER BED C1 Distance to nearest: Well Foundation PropertyR r�, SFR ICF P D1�IiSi," SEEPAGE PITS 11 Depth Size — Number SUMPS LI 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."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 persons subject to workman's compensa- tion laws of California." The applicant must call far IIrequired inspections. Complete drawing on reverse side. C Signed X Title, Date: �� 9 o`-- FDEPAA N Application Accepted by Date a Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT OUE AMOUNT REMITTED H RECEIVED By DATE PERMIT'NO. INFO � _ r,06 I EH 14,26 -