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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)46$-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 siade In compliance with Sao Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. y� �FPo � oSa-3 as- io Job Address S Cityr �� Lot Size/Acreage Rtl /lv x{40 56kt77101--•fJ >a,Y�j i SI STT- 3rd I t Owner's Name Address fJ �,l 7 § P3q - - Phone se&01a5 ?off x ��fJ�/7� Contratlor 51�/L S �/X2 0/ TInN�lddress 9 ( 's, No P�hr�e� a _ ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK d/._a____ SEWER LINES r, . DISPOSAL FLD.. A 114-/ PROP. L1NE'v U FOUNDATION AGRICULTURE WELL af1� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation flim. of Well Casing _ - ' C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �ly� d I'1 Public Cl Other n Delta Depth of Grout Seal 'V i1J/ Type of Grout 4 621vv r.. I I Irrigation Q Approx. Depth I I Eastern Surface Seal Installed b -d Repair Work Done U Type of Pump H.P. Stade Work Qone ' Wap Destruction ❑ Well Diameter Sealing Material i Depth f,/ Depth 7J� Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial._., Other Number of living units: Number of bedrooms 6 Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. b Length of Anes Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' 1 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 oenifies the following: "I certify that In the performance of the work for which this permit is issued. 1 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 must all for all re uirgd inapecti n . Complete drewing on raver a side. < Signed Title: Date: 3 ' FOR DEPARTMENT ON Y App tcalion Accepts by — C �. Date -30 Area 33 Pit or Grout Inspection by Date Final Inspection by Date. Additional Comments: ' Applicant - Return all copies to: San Joaquin County Public Health Services ,0! Suvirontnental Health Permit/Services r 445 H San Joaquin, P O Box 2009, Stkn, CA 98201 FEE IINFF1O, AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No.