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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA95201 R PERMIT EgPIRES l YEAR FROM DATE ISSUID (Complete in Triplicate) Application is hereby all to San Joaquin County for a permit to construct and/or install the vont herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 51119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �j Job Address 77. City, �f Lot Size/Acreage ScIITk—:.3�I Owner"s Name Address q j Phonr 3 nee No � P1r�rYer� Contractor,60/ ddress � � TYPE OF WELL/PUMP: NEW WELL ❑ IWELL REPLACEMENT n DESTRUCTION ❑ Out: of Service Well .❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK A/ SEWER LINES ��- DISPOSAL FLD..A /Az PROP..LIN E'i_.Z�1 FOUNDATION AGRICULTURE WELL _ OTHER WELLv/00- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f = y Cl Industsial ❑ Open Bottom ❑ Manteca 1i Dia. of Well Excavation ;0k",0— �'� Dia. of Well Casing , rl Domestic/Private C1 Gravel Pack L7 Tracy. Type of Casing cif �n �0— .. Specifications 15, d I'1 Public 1:1 Other 1`I Delta A ° Depth of Grout Seal ^" /12 r Type of Grout � �f I I Irrigation 1LL Approx. Depth I I Eastern Surface Seal Installed b '5-41/4-5 X_-V9' IZ ?t2_r4-��:ZEP 1/1(fp< Repair Work Done 0 Type of Pump i! H.P.- Slats Work one Well Destruction 0 Well Diameter � .� Sealing Material.& Depth / - Depth _ y r __- ."Filler Material i Depth in _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADO1TION I I DESTRUCTION i 'I INo septic system permitted if public &ewer is _ available within 100 feet.I ' Installation will serve: Residence _.__ Commercial_ Otlier i Q Number of living units: Number of bedrooms } Character of soil to a depth of 7 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments v PKG. TREATMENT PLT.Q Method of Disposal Distance to nearest: x Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED t=1 Distance to nearest: Well Foundation Property Line 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, an rules and regulations of the San Joaquin County ' Home owner or licensed agent's signature cenifies the following: 'Et 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 workrn'en's compensation laws of California."Contractor's hiring of sub-contracting signature E 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." 1 The applicant must all for all ra viral Inspgcti no. Complete drawing on revere side. ! Signed Title: Dated r I 4 f EPARTMENT6U ON Y + Application Accepted by Date Area Pit or Grout Inspection by Date ``y Final Inspection by Date Additional Comments: Applicant - Return all copies :to: San Joaquin County Public Eleaith Services Environmental Health Permit/Services ' .r 11 41145 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 �� INFO AMOUNTDUEAMOUNT REMITTEDJ; CASH RECEIVED by DATE PERMIT'NO. 00 fM I3•21 tREV.tin fl r»"i .