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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIOW", _.. 445 N SAN JOAQIIIN, PHONE (209)468=342.0 P 0 BOX 2009, STOCKTON, CA 95201 (ZC0 ^ PERMIT EXPIRES 1 YEAR FROM DATE I SSUE (Complete in Triplicate) F;� �.rl�T/;;L'�E��L- 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 Sea Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f Job Address ' CiryL / /G�/Vr Lot Size/Acreage Owner's Name Address )e4' kX-5!kPhone - tS ' I /�� GcJ ,vJ W,tJ. X71 -A v,� �Ql�) Contractor �t� 1f J Rr Address License No.5� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE&;R- n or ng Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 5Z - DISPOSAL FLD. 14,;�g_ PROP. LINE �`/� FOUNDATION A% AGRICULTURE WELL — -- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing ,K Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing Specifications �] , 1', Public n Other n Delta Depth of Grout Seat Type of Grout,ly��'�� I t Irrigation _Approx. Depth <Eastem Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Wall Destruction ❑ Well Diameter. Scaling Material i Depth C — Depth :3Q � Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feat.) 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.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sue Number 5 SUMPS LI Distance to nearest: Well Foundation Property Lina rn DISPOSAL PONOS ❑ l 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 parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "t certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applicant st I I r s. Complete drawing on reverse side. c� Signed Title L��LrJC'!�% ,-- Date.- ` FOR DEPARTMENT USE ONLY Application Accepted by Date O ' �.Ll Area A& - Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all 1pi,es to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CX s RECEIVED BY DATE PERMIT'No. INFO CASH . SH 17.24 IREV.k/w91 1 .� ��.`..r •O� r�� 1� _" 4r lL l EH a-2s