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APPLICATION SAN .lOAQUIN COUNTY PUBLIC HEALIHSERV (� ENVIRONMENTAL HEALTH DI I 445 N SAN JOAQUIN, PHONE (20 P 0 BOX 2009, STOCKTON, CME) 1W MIMS PERMIT EXPIRES l YEAR_FROM DATE•.$ UED . (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 _ � =� F' T rxi� iC� City Lot Size/Acreage r Owner's Name k Address S 14M CC Phone 1 Contractor ' Address ��-611 181W=4 License No.� 5e7. Phone M TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of'-Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well t r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public 1:1 Other Fl Delta Depth of Grout Seal Type of Grout 1 I I Irrigation —Approx. Depth' It Eastern Surface Saul Installed by ) j Repair Work Done L] Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth l TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION bf:, DESTRUCTION I I INo septic system.permitted if public sewer is available within 200 feet.) Installation will serve: Residence-L<l :'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 i Distance to nearest: Well Foundation Property Litre f LEACHING LINE 'Ei- No. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: Well r Foundation Property Line 1 ` - r SEEPAGE PITS Depth r _Size Number SUMPS Ll Distance to nearest: Well `Foundation 29 Property Lina DISPOSAL PONDS ❑ I 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 i rules and regulations of the San Joaquin County I ��....�LL..... 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 ; 1' 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 f r all req red i spections. Complete drawing on reverse side. Signed X t7Y1:� Title: oL-p A iffAC,_ .: Date: 4a- 6 `c73 FOR DEPARTMENT USE ONLY Application Accepted byDate Area _1Z1 Pit or Grout inspection by Date Final Inspection by Date (a Additional Comments: Applicant' - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, O Box 2009, Stkn, CA 95201 S b 0 0.FEE 1[�`2� )NFO AMOUNT OVE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EM 13-24(REV.i/KS) i, � -13 rl�w�•�/ EH 11-26 / G(y 'f I i r� i