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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 � J M p(„ ae4c �';4-%,N �j1 , l\ d . City L-001 Lot�jSize/Acreage _ Owner's Name sTJta,y-, _�(� d-r r4CJ?.Ino Address (-��S �1 J !�� n a-K!7� Phone �A Ir fn ficy cr tnn,p Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well f! PUMP INSTALLATION ❑ SYSTEM REPAIR LI OTHER ❑ Monitoring Well C 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 Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public Il Other ❑ 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 _ •� l t• Well Destruction ❑ Well Diameter Sealing Material & Depth s� ,— Depth Filler Material & Depth v TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I 1 INo septic system permitted it public sewer ise available within 200 feet.) Installation will serve: Residence_ Commercial _ Other ,I Number of living units: _ Number of bedrooms Character of wil to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line _ LEACHING LINE CI No. & Length of lines Total length/size L� FILTER BED ❑ Distance to nearest: Well Foundation Property Line f, SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation_ Property Line I. DISPOSAL PONDS ❑ JI 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, an. 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 no employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signatu certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compact tion lawn of California." The applicant must all for all r aired inspections. Complete drawing on reverse side. Signed X - — Title: ✓ Date: 1,e FOR DEPARTM N� € T USE ONLY Application Accepted by �� L� Date^/ Area Pit or Grout Inspection by ate Final Inspection by IFi 1,.-4,f!z Dete/ F'f Additional Comments: rr—� Applicant --8e rn"t all copies to: San Joaquin oun y u c efl t Services Env- -445 N San talJoaquin, urn,Health Permit/Services - 9 - 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE / NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. {� y1 EH 1244IREV.1/"5) 1�•� ,,,t � �� QIP• �_ FH 114!