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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 DEC 14 . P O BOX 2009, STOCKTON, CA 95201 _ PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby rade 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 amd Regulations of San Joaquin County Public Health Services Joh Address zf r 7 S 6ea/G, � r'� ✓� City L Lot bize/Acreage / n IL /� //`1! / / Owner a Name vt—I C./ ' ! t�p Address t'/� j]e7 L - �! �e�cor� Phon " OIS4 I Pa SQA l6-187 q q(, 7�7 Contractor �If Address lb I-c-La- GA 4�5r>' License tV0 5�Z� ` r Phone - 5- !Z -- Contractor OF WELLlPUMP N WELL.0 WELL REPLACEMENT i 1 DESTRUCTION 0 Out of Service well 0 PUMP INSTALLATION © SYSTEM REPAIR 0 OTHER O Monitoring Well Ll 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 C} Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I I Ptibtic I 1 Other n Delta Depth of Grout Seal Type of Grout I I Irngdtion _ Approx Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H P State Work Done Well Destruction Q Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION l I lNa septic system permitted it public sewer is . evadable within 200 feet 1 Installation will servo Residenco — Commercial — Other Number of living units Number of bodrooma Character of moll to a depth of 3 feet Water table depth SEPTIC TANK ❑ TypelMfg Capacity No Compartments PKG TREATMENT PLT 0 Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE 0 No E Length of linea Total length/size FILTER BED C1 Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 1 1 Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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•contracung signature candies 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 non laws of California ' The applicant m call f II required insp fictions Complete drawing on reverse -s'id`e- Signed X - Title !J L f 6r 4 Date r Q FOR DEPARTMENT USE ONLY f Q D Application Accepted by D. `� 'D • Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments 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 95202 FEE AMOUNT DUE AMOUNT REMirTED CASH RECEIVED By DATE PERMIT NO INFO ] n ��/�, _ !y1q88-7 p 4 EN t72t IAEV iinsr 6 f59 D� '^r ? V*0 1153�. t r`�'�jd IL.. 10 '9� q8 8 !