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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 5 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Healtth� Services. /J Job Address 70 66 t� lve4k� , 'm City Lot Size/Acreage f a �CriZ/fes Owner's Name �[�LJw�a� 10,/.GAAi Address � Xao 4� Phone Contractor,AA9// W � n. Address Qufe � a License Noo �y.�y� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [".1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public El 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 ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material L Depth O Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION 1 I DESTRUCTION I 1 (No septic system permitted if public sewer is � available within 200 Icet.l _ Installation will serve: Residence_ Commercial_ Other /%ucle tldMB Number of living units: _I Number of bedrooms J Character of and to a depth of 3 feet: G/O ,y Water table depth Ze / SEPTIC TANK ❑ Type/Mfg L.Onc,oA;0_ Capacity U 00 No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well _�� Foundation Property Lina 1sL,Y a LEACHING LINE No. 6 Length of lines a— �9 Total length/size FILTER BED CI Distance to nearest: Well�{�`Foundation /011 Property Line , SEEPAGE PITS (7( Depth a r/`' Size s. N/Iumber ale SUMPS LI Distance to nearest: W II oundation� Pfopeny 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; "I certify that in the performance of the work for which this permit is issued, 1 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 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 compensa- tion Ism of California.- r The applicant call for all r ed inapgctio s. Complete drawing on reverse side. o Signed Title: 4 Date: OR DEPARTMENT USE ONLY Application Accepted by / 1....n Date G —� Area 0 `LI4�Pit Grout Inspection by d' ,Date 1- 3 Final Inspection by ' o Date "/1�Onional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services N San ee 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNNTT/REMITTED CASH RECEIVED BY DATE PERMIT 0" 111 EN EH 1x.�IREV.I/As) /�/ ..0� �/ I LTi 0��iQ �r l.y d� 4( 119 7.7