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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH !SERVI&S 3 Z Q ENVIRONMENTAL HEALTH D I V I S ON "----- 445 N SAN JOAQUIN, PHONE (209)468-3JJJ4�I P 0 BOX 2009, STOCKTON, CA 9 20 —_---- PERMIT EXPIRES 1 YEAR FROM DATEIISSUQ (Complete in Tripli ,ate)I : Application is hereby mde La San Joaquin County for a permit to construct and/or install_._ l the—pereln describe 1's application is made in compliance with Sao Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address —7 City_ Lot Size/Acreage Owner's Name ___/C1m �� Address !.� !J 3 ',io. 'hi�.1/ phone Contractor Address�0 /i�ryy^F'I_icense No .ZJ�."i'T,Tz? Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 O Open Bottom ❑ Manteca Dia. of Well ExcavationP 1 Well Casing (� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o1;Casin9 I'I Public 1:1 Other (l Dena Depth of GroutSeal __ _ _ /i/Ar, y *e fg �'i I I Irrigation —Approx. Depth I I Eastern Surface Soul Installed by SAA, �7�� Repair Work Done Cl Type of Pump H.P. L`41ar Q(�A. Well Destruction ❑ Well Diameter Sealing Material L Depth �'�"/� Depth Filler Material A Depth A( fR TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION X DESTRUCTION I I (No septic system F "+V I public sower is available within 200 fest.) �V Installation will serve: Resilience L Commercial_ Other Number of living units: �_ Number of bedrooms Character of and to a depth o1 3 feet: 404-TI Water table depth \I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Distance to Method of Disposal nearest: Well��r Foundation L{� property Lim LEACHING LINE Sd T - r(( No. b Length of lines �T�oota,-l-length/size � FILTER BED Cl Distance to nearest: Well_� � Foundation =7f Property Line 5 C?O'y-�'T SEEPAGE PITS ( I Depth 115 Si" -41 Z-42X Q Number SUMPS Distance to nearest: Well /r Foundation 4� � �llffl_>� � Property Lina-fes=T DISPOSAL PONDS ❑ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and S rules and regulations of the San Joaquin County ` Home owner or licensedent's canities the following:ap signature g: "1 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 workmen's compensation laws of California." Contractors hiring or sub-contracting signature Certifies the following: "1 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 forafl required inspections. Complete drawing on reverse side. Signed X 44 ,A Title: '�r�..-�'�`t��'.�. ... Date: .FOR DEPARTMENT USE ONLY O Application Accepted by tC Date Z ` Area Ph or Grout Inspection by Date Final Inspection by Dat Additional Comments: 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 INFO AMOUNT DUE AMOUNT REMITTED H /CCE/IV(ED BV DATE//�y PE.RM�IT'NO. r fel r1 M("W ,vx sl /( / I I D (�� ! I2j)