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I I APPLICATION o SANO pp ,,µµ J AQUIN COUNTY PUBLIC HEALTH S�WIQE © l ENVIRONIIRNTAL HEALTH DIVISI I�], 445 N SAN JOAQUIN, PHONE (209)4 L W� I � P O BOX 2009, STOCKTON, CA 9 2DI PERMITIRB 1 YEAR FAC OY D I UED (Complete in Triplicate) 1-0 Application 1s hereby made.to 8" Joaquin County Tor a permit to construct and/or install the work herein descr .,r—'' j-j:: 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, Jbb Address y ra ✓ ✓ ,- city Lot Size/Acreage 15/0 Owner's Narne / fwx q%a 4 22y i ddress. Z5 4_ 2eZfQ G LY Phone 5 C19' O)S -A k Contractor Address ID License No. Phone TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 146nitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURt WELL OTHER WELL. PITS%SUMPS INTENDED_ USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ©Open Bottom p Manteca Dia. of Well Excavation Dia,of Wofl;Cssing f7 Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing 5pacifir:atiarts 1'I Public I 1 Other i 1 Delta Depth of Grout Seal Type of Grout I I kdgalitx, --Approx. Depth I I Eastern Surface Seal Insralhid by s� Repair Work Done '❑. Type of Pump H-P. ___._ State Work Done_ Well Destruction D Well Diameter Sealing Material k Depth 7� Depth Sider Material i Depth 4 TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/AODITtON I I DESTRUCTION INC septics tem LA system permitted' public sewer is available within 2O0 feet.l - Installation wNl serve. Residence Commercial_ other - Number of living units: Number of bedrooms v Character of SON to a depth of 3 feet: Water table depth a_ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Wel Foundation - Property line 111 LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Pr operty lute if SEEPAGE PITS I ) Depth Size Number I SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and fulas and regulations of the San Joaquin County ; Home owner or licensed agent's signature certifies the following: '9 cartify that in the performance of the work for which this permit is issued,1*hall not employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring of sub-contracting signature Certifies the following: I certify that in the performance of the work for which this permit is issued.I$11011 employ persons subject to workman's compensa- lion laws of California." The applicant must call for all required inspections. Complete drawing an reverse side. Signed Title- c�� Date: ,U FOR DEPARTMENT USE ONLY Application Accepted byDate �-' 1 r Z i Aran Pit or Circuit Inspection by Date Final Inspection by a, a,64atill , 4 Additional Comments: z� 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 95201FEE k WZZ INFO AMOUNT EIt1E AMOUNT REMtTTEO K RECEIVED BY i 77' CASH DATE PERMIT'NO. . EN 13.24 INEV.111151 �� h EK tate