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APPLICATION SR # 00 l y SAN JOAQ IN COUNTY PUBLIC HEALTH SERVICES 1 1 AID # `�l� � IRONMENTAL HEALTH DIVISION �' 445 N S JOAQUIN, PHONE (209)468-3420 O% 2009, STOCKTON, CA 95201 ��r`° t. IRES 1 YEAR FROM DATE ISSUED NV # lete in Triplicate) AppllcaLluu ty 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. Job Address _ l� 14� city Lot Size/Acreage %Citi A�G ry1 -C= Owner's Name —�• T AJ Address f S;2-47� - Phone Contractor - Address 211sr:_ <L'711i License No. Phone A--Z7J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 r ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Packs ❑ Tracy Type of Casing_ Specifications i I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout I I i Irrigation —Approx. Depth l 1 Eastern Surface Sedl Installed by Repair Work Done U Type of Pump H.P. _ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 6 Depth � - Depth Filler Material i Depth f TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION X DESTRUCTION 111No septic system permitted it public sewer is / available within 200 feet.l ✓ a Installation will serve: Residence Commercial_ Other RE v f s ccs f,U Number of living units: --./— Number of bedrooms -4- Character of soil to a depth of 3 feet: C LA:ir _ Water table depth r SEPTIC TANK. ❑ Type/Mfg 1--!3 -r-'.1 N� Capacity No. Compariments U] PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines � ' Total length/size 949' FILTER BED Cl Distance to nearest: well 4' Foundation Property Line rSEEPAGE PITS I I Depth Size 1 ' Number SUMPS LI Distance to neafest. Well Legrg Foundation ' Property Line ha' DISPOSAL PONDS ❑ I hereby certify that I have preps rgd 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 oaquin County Home owner orlicensed 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 performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- _ tion laws of California." The applicant must tali for all required inspections. Complete drawing on reverse side. Signed X_ Title: _ _ „,,....�.. Date: ,�~� ' •� t - R D ARTfN T USE ONLY I Application Accepted by ��- _ __ Date Area e-_-ZZ k , Pit r Grout Inspection by Date .Final Inspection by CwL, Date%rGl? Additional Comments: k 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 FEC INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. EA 3-24• FH 11426(REV.v n sl /