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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 coaa111mce with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. r VJob 2 MZ �"Address CA'd Vs. �/[1 (f City oln Lot Size/Acreage 1KOwner's Name �v w Phone " 3x Y�Contractor (0017� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WEL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ STEM REPAI ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE At. OTHER WELL PITS/SUMPS _ I` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of a xcavation Dia. of Well Casing ❑ Domestic/Private Ll Gravel Pack ❑ Tracy Type f Casin Specifications I'l Public ❑ Other f� Delta D th of Grout at Type of Grout I I Irrigation _Approx. Depth I I Eastern uAace Soul Install by Repair Work Done U Type of Pump H.P, tate Work Done _ v Well Destruction ❑ Well Diameter Seal Material i Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) /V Installation will serve: Residenoex, Commercial_ Other I� Number of living units: -4— Number of bedrooms /d4 t Character of and to a depth of 3 feet: _ Water table depth (� SEPTIC TANK ❑ Typo/Mfg VA Capacity No. Compartments ev\F(11' PKG. TREATMENT PLT. ❑ r Method of 'apo al Distance to nearest: Well SO� oundation `o Property Line �\ LEACHING LINE No. 6 Length of lines Total length/size /JI FILTER BED ❑ Distance to nearest: Well oundation Property Line � c SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well .[Z Foundation�cc-�n Property Line POSAL 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, a x.. 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: "1 conify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compoi tion laws of California." /The applicant us1 call for all required,inspe.�VeT,,ns. Complete drawing on reverse side. /Y Signed X, J-f �/�"'-✓ Title: ��l.Y�-PYV� Date: 1' FOR DEPARTMENT USE ONLY Application Accepted by "`"t`^^^ •"x LCL��•J,IJLd Date ea-- ✓` t V Pit or Grout Inspection by Date Final Inspection b Date2Z 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 IN Fl AMOUNT DUE AMOUNT REMITTED CASH( RECEIVED 9`/ ATE P 'E RMITNO. ((�� `• EH 1}2x IREV.irnsl N PQII tf�� ?�J _ �x� l/ J7 EH 14 - 1