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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 made in compliance with San Joaquin County Ordinance No 549 and 1862 and the Rules atsd Regulations of San _ Joaquin County Public Health Services .lob Address �y + �� 7 City feLl(1 �'!� Lot Size/Acreage Owner s Name 1I rvt ` �'�/rif�a 4.i�f G CAddress C''w� 1 ! ,✓id i'1 /T�f�K r�n Phonl6zG�1✓ Contractor �i � �'t��rt1.,�rJrrc'� Address License No 4177 4-`'Z6 le- Phon O 7 TYPE OF WELL/PUMP NEW WELD WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLALTIONZ SYSTEM REPAIR Zj OTHER ❑ Monitoring Well DISTANCE TO NEAREST SEPTIC TANK SEWER LINES > SGS DISPOSAL FLD >h'62 PROP LINE FOUNDATION f - AGRICULTURE WELL7-LL'/) OTHER WELL�„LPe - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr CI Industrial ❑ Open Bottom 0 Manteca Dia of Well Excavatwn ID Dia of Well Casing N Domestic/Private ❑ Gravel Pack t ❑ Tracy Type of Casingpecifications I I Pubirc ;A Othgr �is/tv 1-1 Delta Depth of Grout Seal 4 Type of Grout I I Irrrgdtuon �Approx Depth I I Eastern Surface Seal Installed by 4 1 f Repair Work Done u Type of Pump H P �-�� State Wofk Dona . - Sr 4 •"� -•� LY dllt Wail A D�struction 0 Well Diameter Lr Sealing Material & Depth 6, .1,tC [`. .a ��- L `% Cc's . t/ 4„J1-11J /v 4 Depth z Lj Filler Material 4 Depth . TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR'ADDITION I ' DESTRUCTION I I (No septic system permitted if public sewer is evadable within 200 feet I Installunn owill serve Residence T Commercial — Other Number of living units Number of bedrooms Character of soil to o depth of 3 feet 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 FILTER BED n Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cernfy 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 l 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 canify 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 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 Irapection by Date Final Inspection by Date Additional Comments Applicant - Return all copies to San Joaquin County Public Health Services Environmental Health Permit/Services 445 t+ Sao Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DtJE AMOUNT REMITTED CK s RECEivED By DATE PERMIT No INFO I CASH . EN1S7siREv ir,yi� 1 ' - I -