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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 and Regulations of San Joaquin County Public Health Services. Job Address -��7 „`�r-2�✓ ��'"� r`c+ �J City r4 a Lot Size/Acreage ILZ .4 uu<.5 - Owner's Name Al U6 /F l x z V6AZ Address Zoo � A5Z Om" Phone .� Contractor Address _V?0 j.jh License No.,9$'� Phone L1� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 17 Other fl Delta Depth of Grow Seal _ Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth U, Depth Filler Material a Depth (J TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: --/— Number of bed corns Character of soil to a depth of 3 lase C( AY Water table depth SEPTIC TANK ❑ Type/Mfg OP AAIJ217S. Capacity &0I No. Compartments PKG. TREATMENT PLT. ❑ L , Method of Disposal Distance to nearest: Well t Foundation /_ Property Line LEACHING LINE ❑ No. & Length of lines — n Total length/size 6 FILTER BED ❑ Distance to nearest: Well _SQ t Foundation Property Line SEEPAGE PITS Depth �'�� Size � Number 1-21 _. SUMPS LI Distance to nearest. Well /929 1 Foundation Property Line DISPOSAL PONDS ❑ 1 hereby cenly 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: "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 canities 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 compensa- tion laws of California." _. The applicant must call for all required /inspection . Complete drawing on reverse side., Signed X.�(r)7n4.t!L /(�/LL! Title: Date: rljr FEW DEPARTMENT USE ONLY fir Application Accepted by C4'i ms`s Date `� `� Area Pit or Grout Inspection by Date T Final Inspection by Date 7 , Additional Comments: F/"E Applicant - ReHealth Services (/lQ Environmental Health Permit/Services {� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 20 ALr-; LCL• _ INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PEAM17 NCO. . EH 1J]a IREv.�r n si I I •'�9�Q �a it 4 VJ Ig`S I � R1� 1 7 ('3 EH tE M