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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I m - ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 . P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) l Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This 3 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 tAServices. �C-) ' a,Z �- Cit L-_gNn \- Lot Size/Acreage Job AddressZZA Y Owner's Name Addresse—_ Phone LrP` i Contractor T^erZ�� '---Address � %, 21?N� 6 c License No. Phone Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION Cl Out of Service We11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTEND ED TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial' 0 Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing Cl Domestic/Private Gi Gravel Pack ❑ Tracy Type of Casing_ Specifications i'1 Public Ci Other 1-1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation; —.Approx. Depth 11 Eastern Surface Seat Installed by Repair Work'Done ❑ Type of Pump H.P. "" State Work Done_ Well Destruction ❑ Well Diameter i Sealing Material & Depth } Depth x=_._., Fillet Material A Depth TYPE OF SEPTIC WORK:'!NEW INSTALLATION_ REPAIR/ADDITION I f DESTRUCTION I I (No septic system permitted if public sewer is r" available within 200 feet.! Installation will servo: Residence Y— Commercial ' Other;. - . Number of living units: Number of b°rkrooms Character bf soil to a depth of 3 feet: L ��Pt"[ fki!AKk ?51el�o Water table depth SEPTIC TANK. Type/Mfg J:AC"__ / - 04'14� _ Capacity tleJ2_0_ No. Compartments PKG. TREATMENT PLT. 0 Method of DisposaL Distance to nearest: Well Foundation Property Line-1 d5t +J-5 LEACHING LINE '@! No. & Lengtfi of lines L-10r Total length/size r e FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS PI- Depth Site . Number - SUMPS LA Distance to nearest: Well Foundation Property Line 1V12 r -1 05 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: "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, t shall employ persons subject to workman's compensa- tion laws of California." The applicant must II or all requi d in pections. Complete drawing"on reverse side. Signed X Title: it�i Dater / F R EPARTIMENT USE ONLY Application Accepted by IN, Date ^ �+ L rester it r Grout inspection bye,,[_ t. Date E. Final Inspection by__ fG V Date J dW Additional Comments: U 9I sw�rn2a/°'{.tc7_ Applicant - Return all copies to: San Joaquin County Public Health Services Envirodmeatal Health Permit/Services 445 N San Joaquin, P O -Box 2009, Stkn, CA 95201 lF 0 AMOUNT DUE AMOUNT RECASH RECEIVED BY DATE PERMIT"NO. . Eli 13-24 IREv.1/K6l . ©� EH 14-26