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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 (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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressNV9 S,7Led City CA-k Lot Size/Acreage Owner's Name Address a7�.Z 3 y t/l�1 Q_✓� _- Phone o3 Contractor Cs�`�/ .eAddress ! .rte License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CI DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well U 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 n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F) Domestic/Private ❑ Gravel Pack L Tracy -Type of Casing_ Specilications I'l Public fa Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material ii Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION WDESTRUCTION I I jNo 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: P_Y Water table depth Z SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line � r LEACHING LINE dr�No. & Length of lines " f oO ,�tZTot9l length/size a FILTER BED ❑ Distance to nearest: Well Foundation L 04" Property Line SEEPAGE PITS I i Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 applicant "callr ired i specti s. Complete drawing on reverse si e. Signed Title: __ F Date: FOR DEPARTMENT E ON X_..- Application Accepted by Date reams 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 INFO jAMOU/NNTT DUE AMOUNT REMITTED CK N ECEIVED BY DATE PERMiT'NOO, . Err 13.2 IREV. x SI EM t{-m i