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C�;-,t, APPLICATION FOR PERMIT � S J AQUIN COUNTY PUBLIC HEALTH,1`SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 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 and Regulations of San Joaquin County Public Health Services. {�r! `� Job Address=er er �� `� Ka ��! �' City Q Lot Size/Acreage kamlerno II• a T PfioneZ� Owner's Nam Address Address Contractor Address l V I rA�Zldlw icense No. 5 z19 g Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ (A14onitoring Well )0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�-- - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL7_77 +PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing2 Ll Domestic/Private &Gravel Pack7 X Tracy Type of Casingcas r lSpecifications I'] Public Ll Other 11 Delta Depth of Grout SealType of Gross I i Irrigation —Approx. Depth I I Eastern Surlaca Seal Installed by r Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 Ieet.1 Installation will serve: Residence— Commercial_ Other TJ Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg Capacity Ntl.��++��yyl�� PKG. TREATMENT PLT.0 ^'RE4il00"—MA I . (� Distance to nearest: Well Foundation Propert 'w4A 4 i0al LEACHING LINE L1 No. b Length of lines Total lent&NJOA FILTER BED Q Distance to nearest: Well Foundation �F1 ", u wlSION SEEPAGE PITS I I Depth Size Number Vi f SUMPS LI 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-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall emplo rs"Iftbi0rft rltma a companss- tion laws of California." The applicant must all for 81 requiirr,90)inspections. Complete drawing on reverse side. Signed Title: &-0 -,s acs FOR DEPARTMENT USE ONLY Application Accepted by — ____ _ __— _ _ _ Date Area Pit or Grout Inspection by Data Final Inspection by Date �ry�� Additional Coments: S[hLC (7�tL (� mS ! c- OC -1 3-3$-JI'v Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 tFEEO AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE /PERMIT'NO. . EH 1�.b 3.11111EV.r/n5) 111%q E11 1