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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 FAX 47-41} Lf lot+"0138 • 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 So 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services Job Address City .i�' '` �' Lot Size/Acreage I Zb Cc r r, fPhon Owner a Name Skit Address Zf -r E- n" ' lvloorei4q-7y �,�r, r�+5 �{-✓G `�S Z� O lzlr'� ,��-. "!�y�� •n Contractor r�C� r ' �r Address �; f+ r, „4 r-;�U<� License No : 5�'~ Pfione TYPE OF WELL/PUMP —' NEW WELL C WELL REPLACEMENT t DESTRUCTION Ci Out of Service Weiz C PUMP INSTALLATION C SYSTEM REPAIR ' OTHER 4 Monitoring Well C DISTANCE TO NEAREST SEPTIC TANK LTC SEWER LINES C DISPOSAL FLO G PROP LINE l l-, FOUNDATION _ �G AGRICULTURE WELL r�'�'� OTHER WELL L r6 r PlT5lSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,�f i Industrial 0 Open Bottom ❑ Manteca Dia of Well Excavation e- Dia of Weft Casing r � IV r l Domestic]Private 0 Gravel Pack D Tracy Type of Casing_ Specifications- N - 1 Public f' Other 171 Delta Depth of Grout Seal 14-1 Type of Grout Irrigation Appro. Depth I I Eastern Surface Seal Instai.dd by Repair Work Done Type of Pump /U� H P State Work Done f f yu/V d"et v t Well Destruction Z Well Diameter Z" Sealing Material i Depth IV,4 Depth I G ` `�^�^r Filler Material & Depth TYPE OF SEPTIC WORK NEW INSTALLATION I i REPAIR ADDITION DESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet I Installation will sorve Residonce_ Commercial— Other Number of living units Number of bedrooms Character of soil to a depth of 3 feet Wator table depth SEPTIC TANK C Type/Mfg Capacity No Compartments PKG TREATMENT PLT 0 Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE Cl No & Length of lines Tolai length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L' Distance to nearest Well Foundation Property Line DISPOSAL PONDS O 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 subcontracting signature certifies the following I certify that in the perlormence 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 inspections Complete drawing on reverse side Signed X_ _ Title Date FOR DEPARTMENT USE ONLY Application Accepted by Date Area 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 0 Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK s RECEIVED By DATE PERMIT Np INFO CASH EH 13-24 IREV t r K 5)