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4- APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 'made in compliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San Joaquin County Public �Health Services. 6 Job Address / ' City Lot Size/Acreage �.�t-� p tv� s�s �0.5• � 33 C/ Owner's Name d rasa Phone Contractor r ddress t�C� r'r�w/V � License No.4121<59 Phone7�S Z7& TYPE OF WELL/PUMP: t NEW WELL ❑ WEL i REPLACEMENT n DESTRUCTION Out of Service Well ❑ PUMP iNSTALLATIO.9 C] 'w SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK 4SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION- ------AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION 6NS -K5 n industrial © Open Bottom ❑ Manteca. . D, e I Excavation Dia. of Well Casing [7 Domestic/Private ❑ Gravel Pack L�'Trac Type.of Casing_ Specifications I'] Public f-1 Other Delta- Depth of Grout Soil Type of Grout I ! Irrigation X. Depth I I Eastern Surface Seal Installed by �.r �. Repair Work Done yps of Pump H.P. t ork Done , Well Destru ' t`$r Well Diameter Sealing Material & Depth _ Depth Filler Material i Depth U �. TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I (No seplic,system permitted if<public sewer is available.within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms t Character o1 soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity--- No. Compartments PKG. TREATMENT PLT.❑ r Method'ol YDisposal tI Distance to nearest: Well Foundation property Line LEACHING LINE, ❑ No. & Length of lines Total length/sire FILTER BED III Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number 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 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 appkcan ust c II for II re uir i ape, ions. Complete drawing on re Me 'd ` Signed X__ _ Title: Data: _ R DEPARTMENT_U5E ONLY Application Accepted byA � r 4Date Z Aran dZ Pit or Grout Inspection-by Date Final Inspection by` Date Additional Commonis:� ++ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C K AECEIVED BY D E PERMIT'NO. . EM 13-24 IREV.1/n 51 � / ] (EH 74.26ILL &0 . R::3W