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�. .. APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALT 2-&_5` ENVIRONMENTAL .HEALTH DIVI C" 445 N SAN JOAQUIN, PHONE (209 G P O BOX 2009, STOCKTON, CA 01 �a PERMIT EXPIRES '] YEAR FROM DA �I p SU (Complete in Triplicat ) # T3� Application is hereby made to San Joaquin County for a permit to construct and/or insta application is made in a descitred---w"s r olthiance with Ban J County Ordinance No. 549 and 1662 and the Rules and Regulation Joaquin County Public Health Se vice Job Address lY r �� x, .kr-" r /�. !a Lot Size/Acreage Owner's Name ._ Address itr'� (s� 011E-SC-16-0t. Phone LOOS- Contractor 42"09 GAF If DJZ111c&9s Address �31 'fes License No: � r3 �a phone _7&5--24,e71 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ A PUMP INSTALLATION ❑ SYSTEM REPAIOTHER C3 Monitoring Well R C7 DISTANCE TO NEAREST:-SEPTIC TANK IQQA /= SEWER LINES 1140A7,57 DISPOSAL FLD&a0X,_ PROP LINE 1� FOUNDATION AGRICULTURE WELL OTHER.WELL PITS/SUMPS INTENDED USE TYPE OF WELL , PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing 1.1 Domestic/Private 1:1 Gravel Pack El Tracy Type of Casing— Specifications I'l Public 0 Other 171 Delta Depth of Grout Seal Type of Grout ) Irrigation p-_�_,Approx. Depth i I Eastern Surface Seal Installed by I-Ep"Ay LF Repair Work Done U Type of Pump H.P. State Work Done,c FAry Well Destruction ❑ Weil Diameter Sealitig Material A Depth 4U U i Depth Filler Material 5 Depth 6 ti TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION4,1 DESTRUCTION l I iNo septic system permitted if public sewer is � available within 200 feet.) r _ u Installation will serve: Residence_ Commercial— Other (41Vt� Number of living units: Number of bedrooms = _ Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK O Type/Mfg Capacity No. Compartments k, PKG. TREATMENT PLT. L7 _ Method of Disposal Distance to nearest: Well Foundation y Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wall Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number �. SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS 0 I hereby candy that I have prepared this application and that the work wilt 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, E shelf 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 shalt employ persons subject to workman's compensa— tion • . tion laws of California." The applicant ust for al require nspections. Complete drawing on reverse side. Signed X_ _._. __ Title: Date: j FOR DEPARTMENT USE ONLY Application Accepted by �.A !�-'` „_,__� Date Area Pit or Grout Inspection by Date Final Inspection by ^ Date ✓2 � Additional Comments: !213_ Applicant -- Return all copies to: San Joaquin County Public Health Services s Rnviroamental Health Permit/Services 3 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE { G INFO fAM'OUNT DUE AMOUNT AEMITTEb C e7CSH RECEIVED BY GATE PERMIT'NO. ; N 13.24 IREV.t i AS) ¢h-� _+ ( i EM 11-26 T I 1 ,'