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y �. APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ; p, ENVIRONMENTAL HEALTH DIVISION j I� 445 N SAN JOAQUIN, PHONE (209)468-3420 i P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 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 madelin compliance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address r ! � r L.l1� r RCI City i 1 p ,JA4,0<-) _ Lot Size/Acreage Owner's Name L !>i!�; __ �-' Address ""� 3G' l /+xd- ``� Ll 1A ri -,PC/ Phone Contractor v,-4% P3)1 11VI ?jfc�Address .(47e� -2 31 lig ,X d License NoJ X2?(tt f= phone --°��t� r TYPE OF WELL/PUMPi NEW WELL;® WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of. Service.Well ❑ PUMP INSTALLATION e9 SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES I�p DISPOSAL FLD.1� PROP. LINE .....,... -.FOUNDATIONS , AGRICULTURE WELL . OTHER WELL -3ZO PITS/SUMPS 'kK? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial j !�I,rOpen Bottom 0 Manteca Dia. of Well Excavation9 Dia. of Well Casing g�� ° 7`Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing-. < -;rw-/_ - Specifications f i'I Public Cl Other i1 Delta Depth of Grout Seat -5,C Type of Grouts r I I Irrigation _.Approx. Depth I I Eastern Surface Saul Installed by lr-pt;" W �r w v Repair Work Dane 01 Type of Pump .ri �� H.P. Q_ State Work Done Well Destruction 0 Well.Diameter Sealing Material 8 Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve 1� Residence_ Commercial_ Other Number of living unitfff`s: Number of bedrooms Character of soil to a.ldepth of 3 feet: Water table depth SEPTIC TANK. 11 0 Type/Mfg Capacity _ No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED I 0 Distance to nearest: Well Foundation Property Line .l SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS !h ❑ 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 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, 1 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 ca$fqr all required inspections. Complete drawing on reverse side. Signed X L,017y f Title: _ ( [� /►J 112 C� .?� Date: / / sir -..Z - � - : , FOR DEPARTMENT USE ONLY tt Application Accepted by Date 4 Z ^ Area f 2 `CC\ I �� Pit or iUrottt Inspection by Data' �2 --Final Inspection by Date Additionaf Comments: I� .ii Applicant - Return all copies to: San Joaquin County Public Health Services I� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IM Q `M AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. II - r Eli 13-2i(REV.�/n � . tH t425Si ` ` • /i fI (/