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APPLICATION I 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) I 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 andegutions of San Joaquin County Public Health Services. �P�- , 08007 Job Address /t //0 1L/_// U ' Ic kle a 2D City 6_104 lOM Lot Size/Acreage ! '7� RX,0tA� S/T. Phone Owner's Name ^, m' • __ .— Address S 9�kd3 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications dZ 1'1 Public CI Other 171 Delta Depth of Grout Seal Type of Grout I f Irrigation w,Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth A TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION X DESTRUCTION "No septic system permitted if public sewer is a Mable within 200 feet.) 11// Installation will serve: Residence_ Commercial_X_ 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 No. & Length of lines Total ength/size FILTER BED 10 Distance to nearest: Well v�r�fT Foundation Property Line ti/D°ofT J I SEEPAGE PITS 11 Depth Size Number I SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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, I shall not employ any person in such manner as to become subject to workman's compensation taws 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 ,for ¢all required dinspections. ,Complete drawing on reverse side. Signed X'/7-se4 fc '` Title: Date: FOR DEPARTMENT USE ONLY 12 Application Accepted by Datej Area f 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, Stko, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CA it RECEIVED BY DATE PERMIT*NO. �__,,:^EH 14-26(R£V.t J n 5):