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APPLICATION • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRAY DATE ISSUED (Complete in Triplicate) Application is hereby meds 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. 54999 " 1062 and the Rules and Regulations of San Joaquin County Public Health 8ervlcee. O� �" Job Address '�' / ��ry 3/C " Lot Size/Acreage / �I ' T��!ev •� Owner's Name Address Phone �T Contractor % Address License No,.giyoov Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPL CEMENT Ll DESTRUCTION ❑ Out of Service Well to PUMP INSTALLA TIO N C1 SYSTEM REPAIR ❑ OTHER El well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4 g ._ DISPOSAL FLD. W � -/-5D PROP. LINE v LII FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S r C7 Industrial O Open Bottom 0 Manteca Dia. of Well Excavation r Dia. of Well Casing f.l Domestic/Privet* ❑ Gravel Peck ❑ Tracy Type of Casing_ Specifications I'1 Public f.l Other (-I Delta Depth of Grout Seal Ty of Gr t c I I Irrigation .w Approx. Depth 1 I Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Dismeter healing Material i Depth Depth 1►iller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 1No septic system permitted if public sewn is available within 200 feet.) l Installation will serve. Residence.-.— Commercial_ Other 60 Number of living units: Number of �o FDCharacter of sell to a depth of 3 feet: EXPI L Water table depth SEPTIC TANK O Type/MfgCapaci y No. Compartments PKG. TREATMENT PLT. ❑ Permitmay have expired wwi loud Method of Disposal .W Distance to nearetworktteiLine d! Hrealth Div' LEACHING LINE Cl No. 6 Length of lin - I�o a lengthisize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS it Depth Size Number SUMPS L1 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 rut"and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the parformance of the work for which this permit is issued, I "M not employ any person in such manner as to become subtect to workman's compensation laws of Catilortua." Contractors hiring or sub•conifecting signature unifies the following: "I certify that in the performance of the work lot which this permit is Esau d, I pall employ persona subject to workman's compene- tion Laws ifornla." The sppli t / c for all it i s� ate awing on r sidee. Sip L / Title- G/ / Date: FOR D YMENT USE ONLY Application Accepted by Dns ~-1 Area -?- Ph or Grout Inspection by Date Final Inspection by Dau Additional Comments: Applicant - Return all copies to; San Joaquin County Public HealthLServices6nvlroanental Heait4 Permit/Serv445 N Sao Joaquin, P O Box 20091FE- AMOUNT DUE AMOUNT REMITTED K RECEJ PER�NF �! . EN 13-24 IREV,I/,e1 C� dL S EN 14-Y