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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p ENVIRONMENTAL HEALTH DIVISION m 445 N SAN JOAQUIN, PHONE (209)468-3420 �a 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 1n compliance with San Joaquin County Ordinance No. 5�9 and 1862 and the Rules and Regulations of San /�y{Joaquin County Public Health Services. rl C //�Job Address SS / le I/141, /( eY ^-� `/ City Lot Size/Acreage 1�V •<'J j/ ,Owner's Name E C`F� 12, A,//�� Address �/ 5L20/ 's �1�� Phone Contractoq Address License No. Phone YPE OF WELL/PUMP: 1� NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service well ❑ !'PUMP INSTALLATION SYSTEM AIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: 'SEPTIC TANK SE R LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI LTURE LL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA C NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia.'ol�ell Casing F.1 Domestic/Private ❑ Gravel Pack ❑3 cy Type Casing Specifications (�.. I"1 Public (-I Other FI Depth of m Seal Type of Grout �!U\ ( I Irrigation _Approx. Depth sten Surface Saul Ins ad by Repair Work Done ❑ Type of Pump N.P. tate Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth O Depth Filler Material i Depth \ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is ({, available within 200 feet.) Installation will some: Residence_ Commercial Number of living units: �_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Typo/Mfg - Capacity _ No. Compartments PKG. TREATMENT FLT.,❑ - , Method off Disposal Distance to nearest Well oundation /S-A AProperty Line LEACHING LINE No. d Length of lines 44 Total length/size FILTER BED ❑ Distance to nearest: Well Sb Foundation Property Line r) a y SEEPAGE PITS I I Depth Size Number �. SUMPS LI , Distance to nearest; Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be dyne 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature wing: "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 applic ust c Y or all required inspection Compl to drawing on reverse side. Signed � Title: Qr� N !n1 Date: 7--,22 Application Accepted Accepted by ArA 4 JA - r— Date Area -b ZS�7+E� Pit or Grout Inspection by Date Final Inspection by Data r v Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ` 445 N San Joaquin, P _ ox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK ECEIVED By D TE PERMIYNO. INFO ',/q( /q EH 13-24EH 14 a!IREV.rrn5 , d // �D((� ✓ ~ / r