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APPLICATION 'G SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SII, 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 grade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. RasaCity Lot Size/Acreage Job Address /J f� Owner's Name Ad res (�� `'' {' — yac+a= Phone RAI�w Contractor ^ �� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION D Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C1 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications VI Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irritation — Approx. Depth 1 1 Eastern Surface Seat Installed by Repair Work Done U Type of Pump H.P. State Work Done, Weil Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION IW—DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.l Installation will serve: Residence a0�Commercial_ Other Number of living units: .__ Number of bedrooms C O Character of soil to a depth of 3 feet: ZAM 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 length/size 2- FILTER BED ❑ Distance to nearest: Well 1=0 a'ftoundation i r Property Line SEEPAGE PITS l 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, an 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 n 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 m t all r fired specti Complete drawing on reverse si e. Signed �= Title: Date: FOR D, A TM USE ONLY Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection b Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 4 / 4455 N N San Joaquin, O Box 2009, Sttcn, CA 95201 FEE AMOUNT DUE AMOUN3 REMITTED k K RECEIVED BY PATE PERMIT'NO. INFO CA . EK 13.2 (REV.1/851 /I ��i /. ' EH 74.75 !