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M APPLICA'T'ION SAN JOAQUIN COUNTY PUBLIC HEAL H%RR41_044151 ENVIRONMENTAL HEALTH DIV 4�} �C 445 N SAN JOAQUIN, PHONE (20 )�54- P 0 BOX. 2009, STOCKTON, CP W4 PERMIT EXPIRES 1 YEAR FROM DA ED (Complete in Triplicata)111V ft Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made 1n Compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health ervicea. �� ' Job Address 5ooCity r Lot Size/Acreage r15-. 3(n i Owner's Name Address �� s� Phone 1 2Z.� Xy S/0 ' Confracf Address �,]f� License No Phone �aJ'` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM•REPAIR ❑ ¢¢FT^•�- OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I AMMUtsALD. PROP. LINE ---- - FOUNDATION _ _ AGRICULTURE WELL ==RECqMPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIOIJ 15tECIfISAJM n Industrial C1a Open Bottom C1 Manteca Dia. of Well Ex vati Dia. of Well Casing [D Dotnestic I Private ❑ Gravel Pack ❑ Trac T N JOA �1Nr Tracy Type of Caps t, cct� rlf'G'� Specifications FI Public 1'1 Other Il Delta depth t�Qt tiN ' ONTyps of Grout I I Irrigation _Approx. Depth I 1 Eastern Surface eaI Installed by 0 Repair Work Done' ❑ Type of Pump H.P. _ State Work Done _ O Well Destruction 0 Wel[Diameter Sealing Material & Depth Depih Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 290 feet.) Installation will serve: Residence..__.� Commercial K Dther 6 Number of living units: Number of b oms Character of&oil to a depth of 3 feet: Water table depth 00 SEPTIC TANK Type/Mfg ..Capacity E200 0 No. Compartments a PKG. TREATMENT PLT. C} ! il Method of Disposal Distance-to-nearest: Well Foundation Z , Property Line LEACHING LINE No. & Length of lines Total length/size X FILTER BED ❑ Distance to nearest: Well�(�� Foundation r Property Line SEEPAGE PITS Depth s Size __Number SUMPS L1 Distance to nearest: Well 50 Foundation fD Property Line DISPOSAL PONDS ❑ t 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 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 subcontracting 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 laws of California.'_' The appficant call to II qui d inspections. Complete drawing on reverse side. �] Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by; +� Date Area Pit or Grout Inspection by Date .Final Inspection by�� Date Additional Comrnenta: _ �6� �. c- 4:�, Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 1 445)N San Joaquin x 2009, S.tkn, CA 95201 ..t • INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. 111-211REV.ira+er // / WV _-Z' 77? 11-2A