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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 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ,l 1 I 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 coMliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. � 7 cy/,�_j l� Job Address + ftl Lan G City =�Y Lot Size/Acreage ti{� Owner's Name Address MNtWff)'Cnf?i'tt CA 941n Phone Z$Z5 E. M ale St i Contractor . Address�; License No. Phone - TYPE F.WELL/PUMP: NEW WELL © WELL REPLACEMENT C'1 DESTRUCTION o out or Service Nell ❑ PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER Vi Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _NA SEWER LINES 7 50' DISPOSAL FLO.N_ PROP. LINE r FOUNDATION 7 r AGRICULTURE WELL OTHER WELL PITS/SUMPS �(�► INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �lrni�f3 ('7ISf ') G7 Industrial ❑ Open Bottom ❑ Manteca Dia. of.�Excavation Co° Oia. ofVwell Casing ` f-1 Domestic/Private G7 Gravel Pack L7 Tracy Type of Casir _ NA Specifications NA l I'1 Public ( Other n Delta Depth of Grout Seal Type of Grout-NA- 11 rout-NA_11 Irfigation Approx. Depth IeEasIer4*dC1tn1 Surface Sew installed by NA .,_ Repair Work Done U Type of Pump h1A_ _. H.P. W State Work Done_ J. � Well Destruction ❑ Well Diameter �NA Sealing Material 4 Depth wA Depth WA Filler Material fi Depth II TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITInN I I DESTRUCTION I t iNo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence— Commercial — Other Number of living units: Number of bedroom* 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 it Ij LEACHING LINE ❑ No. & Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Property line 0. SEEPAGE PITS ;� 11 Depth Size Number II E SUMPS t Cl ^Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ " I 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 j Home owner or licensed agents 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'iiior 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." i The applicant must call for all required inspections. Complete drawing on reverse side. LW,,� yi Signed x a Title; FOR DEPARTMENT USE ONLY 9 �I Appficatign Accepted by G2 Date Pit or Grout Ina rt7 (J pectian b Date Final Inspection by .� Dace Additional Comments: 4� f •f Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services SO 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ij Cl, EEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE � PERMIT'MO, IMF CASH r / /��j y� . EH 13,24 IREv,tIAS)V `� �( / 3(U �F,�1 [� �Q� Y✓ U 15 I EH 14.73 C0 CS Ct�� L [`� 7