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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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. 43 Job Address i%` City ; Al e 40 Lot Size/Acreage Owner's Name See {j=tZ`- — AddressDC7�1 S� t4?�i"s Phone _ 331 Contractor tt dS k1 .J/l�k�dkAddress & Or }�F�"� �1 L�9�JS&3• License N0..fy��ZrL� Phone_7 �_� tt TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ]fes_— SEWER LINES J60 _ DISPOSAL FLD., �� PROP. LINE 9'0 FOUNDATION : — AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial (Open Bottom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing C Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing L Specifications J Z I'l Public (1 Other n Delta Depth of Grout Seal Type of Grout '.J c I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by"D a d %) Repair Work Done ❑ Type of Pump .J Cy H.P. 2 State Work Done _ yr Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Materiel & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well _ Foundation _ Property Line SEEPAGE PITS 11 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 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 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 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 ust ror all equired ' spections. Complete drawing oon`'reverse,�e. Signed X Title: C. , ' Date: C� DEPARTMENT USE ONLY Application Accepted by ✓ Date —b Z Area Pit or rot Inspection by ate � Z Final Inspection by7- atei� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 %z /w FEE AMOUNT DUE AMOUNT RCMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH • EH 13-24 MEV.I/Msr (V (,,�- /� EH t4.2E L/�j 3 ! 0 C, � �S 'Z,1� ] j/1 �J