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APPLICATION S..� JOAQUIN COUNTY PUBLIC HEAL. 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. ^ Job Address 1 C� '� 4 , �� f'S City t- Lot Size/Acreage -S 1"aC.Zr'S Owner's Name r--� %v �� eti\ Address 6-loR t c-rte Phone Contractor C� �<=- S`�* �<- Address f ', <E -- �'+� -- License No. `30`73 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —_ DISPOSAL FLO. PROP. LINE FOUNDATIOR-. _AGRICULIVRE.WELL .OTHER.WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I"l Public 1.1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by — Repair Work Done U Type of Pump N.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION P< REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence n Commercial . Other Number of living units: Ii Number of bedrooms C Character of soil to a depth of 3 feet: C Water table depth �% f SEPTIC TANK & Type/Mfg m_ Capacity ;bLcaZ No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal _ Distance to nearest: Well _ Foundation Property Line tClJ LEACHING LINE V"- No. & Length of lines (7� ��' r LF>E�y Total length/size % (� FILTER BED ❑ Distance to nearest: Well /-LL) Foundation L:?iO Property Line /UG SEEPAGE PITS Ijl�` ;' pth � �r Size y.a�r Number y _ SUMPS LI Distance to nearest: Well _L570 Foundation :�212 , Property Line Jf�U 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 Joaquin County Home owner or licensed agent's signature certifies the following: "1 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 beccihna subject to workman's compensation laws of California." Contractor's hiring or,sub-contracting signature certifies the following: "I certify that in the per.tarMance.pLthe.work-for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must /II for all re weld inspections. Complete drawing on revarse side. Signed X JJ 61/1 V=/ _ Title: /,�- �57elDate: Iy FOR DEPARTMENT USE ONLY r Application Accepted by Date (/��r —�� Area �� /rlr or Grout Inspection by Date (Final Inspection by Date C/ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFOLL u C�AJSrH� t �7 EH 13-24(REV.lin5)` 1 !.�Ff✓ FF„1. -01 EH 14-2E