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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH 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 (CComplet_e.in .Triplicate) Application in Hereby wade to Satz Joaquin County for a permit to construct and/or in%tall the work herein described. This application is Riede in eowliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address (� ' "� - City Lot Size/Acreage 1,15 Owner's Neme a Address Phone 46 Contractor z4<--d _ _ Address License No---?CS-1W -Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION ❑ Out of service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Hell Cl 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 CO(YSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia_ of Wan Excavation Dia. of Wer Casing Cl Domestic/Private ❑ Gravel Pak7 ❑ Tracy Type of Casing Specifications I"I Public f_l Other Fl Delta Depth of Grout Seat Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ WON Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence v Commercial— Other Number of living units: ,t— Number ofooms Character of sol to a depth of 3 feat: ti Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line 6 LEACHING LINE 17FrNo. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Wan Foundation Z4 _ Property Line /25- SEEPAGE PITS 14�i)epth +��~ 1 - - Size r / Number t SUMPS Ll Distance to nearest: Wen /Sb r Foundation Property Line �S DISPOSAL PONDS ❑ 1 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 lollowing: -I canify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contfacting signature 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 Lowe of California." The applica m call fo alt rsquir i ons. Complete drawing on reverse side. Signed A Title: - Date: aFOR DEPARTMENT USE ONLY t� Application Accepted by c.�ofc[�' k A - -- Date �O' p��-�Z Am �L—T ��y� ��i'�/ /� � f �or Grout Inspection by ate ""?-Final Inspection by Date 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. INFO I . _.. . �/3