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APPLICATION 4E�/W,6 SAP' JOAQUIN COUNTY PUBLIC �' ERVICES L(gail ENVIRONMENTAL HEALTH r�i•:�^��" 445PNSAN 0 BOX 2009,009, STOCKTON, 0 -3420 PERMIT EXPIRES 1 YEAR FROM D S Rlal (Complete in Tripli Application is hereby mede,to San Joaquin County for a permit to construct and/or install the work herel destV. This application is made in compliance with San Joaquin County Ordinance No. .549 and 1862 -^y�,'a•. San Joaquin County Public Health Services. Lr V Job Addis t�6 City Lot Size/Acreage Owner's No - Address Phone � 397� �rniZt2�4 �3� - t Contractor Addres icense No.- Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C]- DISTANCE 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameterjka _- Sealing Material .ac>< ct Depth Filler Material A r ` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DIpJTAUOTIt3N pt Mao septic system permitted it public sewer is yy FF1111CC JJ UU available within 200 Iset.l Installation will serve: Residence2 CommercialOther SAN JOAQUIN .• - Number of living units: 1— Number oJ, rooms PUBLIC HEALTH �El— i Character of sof too depth of 3 f9an �1 ENVIRONMENTAL HEALf r Water Eable depth SEPTIC TANK ❑ Type/Mfg Capacity ! No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE Jif' No. 6 Length of lines ��,�11,..,. Total length/size FILTER BED ❑ Distance to nearest: Well f1J_ Foundation + h N Property Line _ SEEPAGE PITS If Depth / Size Number SUMPS LI Distance to nearest:--�oll � Founds lin—'E;e3 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: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mentor as to become subject to workmen'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 employ persons subject to workman's comport". tan laws of California." The applicant must all for all rjest (ons. Compl `drawing on reverse side. Sip Title: F Date: FOR DEPARTMENT USE ONLY ral,� (Application Accepted by Date ' Area Z 1 Grout inspection DY i Date L Final Inspection Dy Date .3 d C/L/ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaqu ln, O Box 2009, Stkn, CA 95201 �P�i7 (1 NEE AMOUNT DUE AMOU REMITTED CK RECEIVED By D E PERMIT NO. `M; (/ ` INF,D . iT EM IYN IaEV.v�SI EN 1431 ` HCl