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t APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I (�� 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIR YEAR ES 1 YE FROM DATE ISSUID (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. 73 'L oALT � ; rt Job Address City Lot Size/Acreage Owner's Name `Sft:g— � Address 6 Phone <i/ Y! ! Y Contractor Address License No. Phone TYPE OF WELL/PUMP-4 NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 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 L_I Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications t'I Public CI Other Cl Delta Depth of Grout Seal Type of Grout 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 ❑ Well Diameter Sealing Material Ll+ Depth Depth Filler Maters I?e TYPE OF SEPTIC WORK: NEW INSTALLATION I i RIr 7 ES pt stem permitted if public sewer is AX MRI Whin 200 feet.) Installation will serve: Residence____ Commercial_ thar ,j Number of living units: Number of bedrooms ��mi� expired Iltat�t Character of Boll to a depth of 3 feet: work hein -00MOIRtAd or Inspetable depth SEPTIC TANK. ❑ Type/Mfgpati ` +� Compartments PKG. TREATMENT PLT.❑ `i c' Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. S Length of lines Total length/size FILTER BED ❑. Distance to nearest: Well Foundation Property Line SEEPAGE PITS I. 1 Depth -Size Number w SUMPS LI Distance to nearest: Well Foundation Property Line ,'DISPOSAL PONDS ❑ 5'ti X 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 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 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 t call for all di tions. Complete drawing on reverse side. l Signed Title: Date: ` / FOR PARTMfNT USE ONLY ] �7 q ,- Application Accepted by ^ Date 4�� 1yt Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 12 V 4a Applicant - Returd all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IN 0 AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERM17'NO, Qr i . 1w_,2V'8�'I EH1 -24rREV.+inS4EH 1 .26 2 L .9 /Com(