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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - . ENVIRONXENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSIIF.D (Complete in Triplicate) Application in hereby made.to Sanlioaquin County for a permit to construct and/or install the voric herein described. This r 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 Service,-srr . Job Address v n � 00 Gam' 6 i city + Lot Size/Acreage �JI Zx T �l - , OZ-09 Owner's Name 0 T4 G0 CX1 NS6 Address 60, SED Phone �- q/S ( � �zQ9� ContracIor � r'�+ � _ ' —Address 12 16. Mp'i m.' ST F_-SC{kLbbcense No.f1Z9 �(1 Phone 6 3 S7'3 c7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well.- ❑ I l Monitoring Well -PUMPANSTALLATION ❑�d a,•: 4,.�.�:.,--SYS,T�,E�Mq REPAIR.❑- r ._,,O HER,❑_ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES V^ DISPOSAL FLD.7� PROP. LINE �0 FOUNDATION AGRICULTURE WELL l00� OTHER WELL 3QL PITS/SUMPS VA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation =--- - _ Dia. of Well Casino n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -• • 4 Specifications - I'l Public Cl Other _ fl Delta Depth of Grout Seal -v Type of Grout -- I I Irrigation _Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump Ti H.P. State Work Done Well Destruction Well Diameter 2 Sealing Material i Depth �eCl-+ 'T a Depth Piller Material i Depth :5kNC> Z �� I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I F DESTRUCTION I I INo septic system permitted if public sewer is S available within 200 feet.) Installation!will serve:- Residence Commercial Other I Number of living units: Number,of bedrooms ., Character of soil to a depth of 3 feet: ) Water table depth I° SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ _ _ .i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i l Depth Size Number SUMPS Ll Distance to nearest: Well a 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, 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 not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the fogowing:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subiect to workman's compensa- tion laws of Csl' ►nla." The aI,plican st call for all requir in p to rawing on reverse side. Signedr 7-14 Title: Ce � Data: FOR DEPARTMENT USE ONLY • Date-. Area �d. Application Accepted by _ Pit or Grout Inspection by Date Final Inspection by 1 � Date Additional Comments: -- Applicant - Return all copies to: San Joaquin county Public Health Services F Y 4451 NSan onJoaquinPermit/Services, v . P 0 Box20091Stkn, CA 95201 S� FEE AMOUNT DUE AMOUNT REMITTED CR RECEIVED BY DATE PERMIT NO. INFO /� / CASH 7 C�+� • EH 13.24IREv-11A5! �fi fJ© (JQ / l�dl�- 3IZYle?3 EH 14.28 l-