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i APPLICATION. X�S ii SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION ��CE � ! 445 N SAN JOAQUIN, PHONE (209)468-34.2 IV f P 0 BOX 2009, STOCKTON, CA 95201JUN 2 6 192 PERMIT MIRES 1 YEAR FROM DATE ISSUEDgNV1RQNMtNTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES ?.Application is hereby made.to San Joaquin County for a permit to construct and/or install to This Japplieation Is made in cawpliance with San Joaquin County Ordinance No. 549 and 1862 and th San ;Joaquin County Public Health Services. Job Address„3?-7f 1�'�-�i M r City i!Ci r� ! Lot Size/Acreage , �I C� Owner's Name ! V r Address31 My S}i T� ,k o�-1J Phone ` 6 �a `;Contractor Dl LT, AddressCS46 � ` C� S'tn/✓ License Nd Phone 114 �6 A-C TYPE OF WELL/PUMP: it NEW WELL ❑ WELL REPLACEMENT 77 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 "DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FdUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E. n Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack7 C7 Tracy Type of.Casing_ Specifications 'f'1 Public fa Other it Delta Depth of Grout Seal Type of Grout ` t.f'1rri0ation Approx. Depth f Eastern 5t,rface 5eui Installed by f 'Repair Work Done 61, Type of Pump H.P. �!-� State Work Done ' Well Destruction ❑Y Welt Diameter Sealing Material & Depth ' { Depth Filler Material 9 Depth L` TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public sewer is 11 available within 200 feet.) E Installation will serve: Residence— Commercial— Other ii Number of living units: 'M Number of bedrooms E; Character of soil to a depth.of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C I Method of Disposal a Distance to nearest: Well Foundation Property Line it 4^� LEACHING LINE Cl No. 8 length of lines - Total length/size FILTER BED a Distance to nearest: Well Foundation Property Line 'i It SEEPAGE PITS I I Depth Size Number .� SUMPS LI Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ E 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 sub-contracting 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 must call for all required inspections. Complete drawing on reverse side. Signed X 1� �f/Z _ -�Fitle: 277 'I OR PARTMENT USE ONLY Application Accepted by Date ran 7 Pit or Grout Inspection by Date Final Inspection b �� Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ;I Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUiNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY ATS PERMIT'NO. ', 1 r EH 13-I4{REV,4/r 51 JOAO]a T�- i EH 74• '� `