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I APPLiCATI ON SAN 'Z'OAQUIN COUNTY PUBLIC HEALTHRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95241 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein'described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _ !.' "!^� City .Z Lot Size/Acreage Owner's Name Address Phone r vp,3 11�� ContractorQ,,,iV,,ddTess License Nof Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT . DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER a Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE 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 El Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing_ Specifications I.1 Public 1:1 Other U1 Delta Depth of Grout Seal Type of Grout - I I Jrri�ation r _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter Sealing Material & Depth .Depth Filler Material i Depth Z I TYPE OF SEPTIC WORK: NEW INSTALLATION lir REPAIR/ADDITION I I DESTRUCTION] I (No septic system permitted it public sewer is J_ available within 200 feet.) Installation will serve: Residence�f_._ Commercial Other Number of living units: __L_ Number of bedrooms Character of soil to a depth of 3 feet: 111 star table depth SEPTIC TANK © Type/Mfg (altion a -t 0 yt o. Compartments 21 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well b Foun Property Line LEACHING LINE L� No. & Length of lines To al length/size FILTER BED ❑ Distance to nearest: Wail D Foundation /8 d Property Line SEEPAGE PITS f'Iepth Size .! -. M Number LIMPS 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 Joaquin County Home owner or licensed agent's signature.cenifies the following! "I certify that in the partormance 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 lawiof 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,'.Vshall 6rAploy persons subject to workman's compensa- tion laws of California." The applicant must call for al wired inspactio a. Complete drawing on rev rse side. . dR 771 Signed Title: _ "✓] t Date: I OR_ DEPARTMENT.USE,ONLY KI-Ii Applica ' n Accepted by Date Area �+/ • I� t v �r ut fn b> ate L� '' el Inspe t by �`" r' L'1/ a t Additional Comments: d� ` r� � I� Applicant - Return all copies tn: bait Joaquia Countq Public Health Sorvic JG Z Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201e7% INFO AMOUNT DUE MOUNT ITTED CASH RE IVSD PATE PERMIT'NO. EH 1 -24irtEV.ve5i ' y *ADW EH 1414-20I / av