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APPLICATION SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CGo�ip.lete 'an Triplicate) Application is hereby made to San Joaquin County for a permit Yto 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 C City Lot Size/Acreage Owner's Name A , (1 . Address a . ZQi 12 Phone S I - i Contractor Address 05ZEAklldale, b 6t License No. X& Phone La TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION $1 f Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS EINTENDED USE TYPE OF WELL' 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing C:1'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications V1 Public Cl Other n Delta Depth of Grout Sea$ Type of Grout t I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump y H.P. Stat@ Work Done Well Destruction Well Diameter 6 Sealing Material & Depth OD Depth 60,� Filler Material a Depth ty TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR1ADDtTION I I DESTRUCTION i I IN6 septi tem permitted if public sewer is C available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number.of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKC TREATMENT PLT.Gl Z,yMethod of Disposal Drst�n�ei.0 nes e*st We '} Foundation' Property Luie LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation— Property Line 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 rules and regulations of the San Joaquin county Home owner or licensed agent's signature cenifies 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 applicant.mus call for all required in ctions. Complete drawing on reverse side. Signed Title: Date: 411419Z D T USE ONLY G3 I Application Accepted by r.All, Date Area a r Pit or Grout inspection by Date Final Inspection by Date /6 92— 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 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13 24 23 1REY.i/fl 51 W D &c r a o V U s fa `'j2� VIT EH 1 lUY/