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APPLICATION Dom"" SAN JOAQUIN COUNTY PUBLIC HEALTH' SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 aA 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 compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /�}} Job Address 11� � It City r4 of Size/Acreage Owner's Name Address lj3qe�, /-•4CZ/2 Slel f Phone. - J II Contractor Address S,L.S /2 License No. .� Jr4'/�_ Phone - TYPE OF WELLIPUMP: V, NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION © SYSTEM_REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK �' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL-292'_ PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rf fl Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin X Domestic/Private X Gravel Pack ❑ Tracy Type of Casing__ Ptah _ Specifications r /� - I'l Public I-1 Other n Delta Depth of Grout .Seal ZdQ Type of Grout I I Irrigation — Approx. Depth 11 Eastern Surface Seal Installed by - Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth i Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I } REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted it public sewer is availabie within 200 feet.l Installation will serve: Residence_ Commercial T Other Number of living units: Number of bedrooms . Charactef`bf soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PET. ❑ Method of Disposal Distance to nearest:. Well Foundation Property Line LEACHING LINE 0 No. 8 Length of lines Total lengthtsize FILTER BED 0 Distance to nearest: Wall Foundation Property Line SEEPAGE PITS f 1 Depth Size Number SUMPS Ll 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 Joaqdin 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 applicant—$Icall for all required i petitions. Complete drawing o reverse side. Signed L7 I Title: Date:AL +FOR DEPART ENT U ONLY n Application Accepted by DateZ Area Z /� Pit or l/ t Inspection by at " 5. `Fina InsAA� pection byate �Z Additional Comments: "14e AWt V.- 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 FEE AMOUNT DUE AMOUNT REMITTED I C K I RECEIVED BY DATE PERMIT'MO. �wJ\ . EH 13.24(REV- w 5 r r Y , o e ?�'� ' ,Z _Z / _ EH 11.126 �J -396