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APPLICATION JOAQUIN COUNTY PUBLIC HEALTH SERVICES SANENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '► (Complete in Triplicate) ,:. I. Application is hereby made to San Joaquin County for a=permit to construct and/or instal]. the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rule and Regulations of San Joaquin County Public Health Services. i1IW Ci, Lot Size/Acreage: Job Address 2 i Phfln ��rx,) 3q l Owner's Name r ,l��T Address �r'"" - F � L (�fJ ddress ✓ "7��i�nse No � Ph6tYe v445 Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well PUMP INSTALLATION _' ��y , ��n/ '>� DISTANCE TO NEAREST: SEPTIC TANK _a.cc�--- AGRICULTURE ELL .a�1�.�. OTHERSWELL"�L_12 L__ PITS/SUMPS � FOUNDATION �-� - - —-- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom ❑ Manteca is Die. of Well Excavation ff - Dia. of Well Casing C1 Domestic/Privets 0 Gravel Pack 0 Tracy .Type of.Casing pj��} �✓0 Specifications '� of Grout 1'1 Public 1-11 Other n Delta i. Depth of Grout Seal Type I I Irrigation lI Approx. Depth 11 Eastern 1 Surface Seaf installed b Repair Work Done L3 Type of Pump H.P. State Work Pone — �/ Sealing Material i Depth Weil Destruction ❑ Well Diameter Depth ?��) Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADO[TION I I DESTRUCTION I I (No septic system psrmitted if public sewer is ._available within 200 fest.) - v 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. Companmants PKG. TREATMENT PLT.0Method of Disposal Distance to nearest: Well Foundation Property Line Q LEACHING LINE L1 No. 6 Length of lines Total length/size H 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line �• 4 k- DISPOSAL PONDS ❑ 1. A 7 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 noty employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certilies 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 all for all re uirgd inspecti ns. Complete drawing on Signed X Title: Date: OR DEPARTMENT LU ON Y F _ Application Accepted by ;a Date Area . `7 ry Pit or Grout Inspection by Date Final Inspection by Date: Additional Comments: r Applicant - Return all copies to: San Joaquin County Public Ilealth Services,., �+�/� T r Environmental Health Permit/Services r 4115 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT OUE , AMOUNT REMITTEDCK CASH RECEIVED ey OATE PERMIT-NO. 4. . INFO .¢. EN+13-24InEv.r/RSr j1Aa f ter' ' EH 1929Apt-