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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388,STOCKTON,CA 95201-0388 r. PERMIT EXPIRES I YEAR FROM DATE ISSIIED X N 1), (Complete in Triplicate) �l\,,opf-„.,, t12 157 Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application 1s malt to complienec�rvith San Joaquin f bunty Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address -kr WA City toeK+6 n Lot Size/Acreage W1 Address LIAM141 Phone- 7 Owner's Name 1 b 7 24 4j(a -k5.2-74- Contractor 1m�X �On `� � ��License No. � Phone TYPE Of WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR_ ❑ OTHER A( "on itoring Well ❑ SaIL soQINy DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y 0 industrial (D Open Bottom ❑ Manteca Dia. of Well Excavation SAO Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications (� l'I Public [-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work D ne _ Well Destruction _w0— Well Diameter Sealing Material A Depth •I only Depth _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i ) REPAIR/ADDITION l I DESTRUCTION I I iNo septic system permitted if public sower is available within 200 feet.) insmilstion will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms P Character of soil to a depth of 3 feet: Water table depth -� SEPTIC TANK l❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 6 Length o1 lines Total length/site FILTER BED Cl Distance to nearest: Well Founaation Property Line SEEPAGE PITS 11 Depth size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 shell not employ any person in such manner as to become subject to workmen'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 persona subject to workman's compensa- tion laws of California." The applican st wired i �ctions. Complete drawing on reverse side. Signed Title: l Date: D—I5— FOR DEPARTMENT USE ONLY Application Accepted by Date C 4 Pit or Grout Inspection by Da Final Inspection by a J ` Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services e-16S � Environmental Health Permit/Services 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388 7— FEE FEE AMOUNT DUE AMOUNT REMITTED CK I GASH RECEIVED BY DATE PERMIT'NO. � INFO Cn • EM 13.24 1ItEv.I/R W EM 1a 2s II l KK// 1