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�.. APPLICATION ..i 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 (Complete in Triplicate) Application is hereby made to Had 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,,$$egulations of San s Joaquin County Public Health Services. d ��jj IP I - Z708D09 Job Address _;Z,/AlNoww zzucr�2misw /2D City.5' 0a_rO ! Lot Size/Acreage /t /� rr_ Cht�i�,vA-�O Vis.=.�,vvJ G Owner's Name !s� C�`• Address 77 1�619�6 `TF sS/ • Phone ,5-917 >tO3 Contractor Address License No. Phone r. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ,— Dia. of Well Casing r. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1-1 Other (l Delta Depth of Grout Seal Type of Grout _ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth A TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRTADDITIONX DESTRUCTION INo septic system permitted if public sewer is �_C/r'� -fes- a "table within 200 le/s't.,).}---�� 44�� Installation will serve: Residence_ Commercial _X_ Other._Vhw�� G• Ql'+-- Number of living units: _ Number of bedrooms s 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 Distance to nearest: Well Foundation Property Line LEACHING LINE p( No. & Length of lines q 9S�ToolalT(ength/size � FT' / 71 FILTER BED 'AI Distance to nearest: Well V~O FT Foundation , Property Line"�Ooofr SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 i/ rules and regulations of the San Joaquin County //r+c' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is inued, I shall not employ any person in such manner as to become subject to workman's compensation taws 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Q Signed X � �1�L Title: -- Date: FOR DEPARTMENT USE ONLY Application Accepted by -"*Zl Date - '/ Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services r Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'NO. • 'N t1 at IREV.rims, .� Y _.. t�J".�M1-1 '1Y Vp,.