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APPLICATION N - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � --r ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Al r V 'F6.� _/UN AA City� e Lot Size/Acreage S, Owner's Name I� -P-�_. �.�. Le Address � �� A IAI �� pone �s Contracto4E1 Address ift-92437 1„R Li License No.ta[$sc0 G 4 Phone S"* 0'7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ rr OTHER ❑ MonitoringI-)Well DISTANCE TO NEAREST: SEPTIC TANK _l0 SEWER LINES tC4_ DISPOSAL FLD.t PROP. LINE / FOUNDATION 1110 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications a I"§ Public f:7 Other (-IDeltaDepth of Grout Seal Q Type of GrouI I I Irrioation _Approx. Dep�tth,,-- IS�I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump � H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth O� Depth Filler Material & Depth Q TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR:ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence— 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 Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of tines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 iignature 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 st I re uired ins ctions. Complete drawing a ever �� Signed X Title: ; 4I t Date: (0 V 7 Z FOR DEPARTMENT USE ONLY p ^� I Application Accepted by Date_ -7�'O Area 4 Pit or Grout inspection by Date Final Inspection by Date011 Z Additional Comments: ,s 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 INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY GATE PERMIT NO. . EM 14-21fREV.1iKSi 3`f.°� 3 Z8z[ta ' _ z c� EH 11.20 4>