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APPLICATION SAN A QUIN'COUNTY PUBLIC HEALTH SEIVICES _ ENVIRONMENTAL HEALTH DIVISIONu 445 N SAN JOAQUIN, PHONE (209)468-3420 j P O BOX 2009, STOCKTON, CA 95201 - ` '`��,J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C/q,3 (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 made In ccmpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San _ Joaquin county Public Health Services. Ii �3'v s' /7y/fl cLAA) Q 7 City A=A Lot Size/Acreage y�0 Job Address i Owner's Name �� Sf/uGN )J. Address S,/YJ/ Phone Sec . 9172-1r Contractor Address -AA Ani Af& f1 !.E License No. S�ySL76 Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION Ll Out of service Well Monitoring Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑. . O DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial -0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1771 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications ' I'I Public Ia Other F1 Delta Depth of Grout Seal Type of Grout — I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by (1, Repair Work Done D Type of Pump H.P. __ State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I RE✓PA/IR/ADDITION YV DESTRUCTION I 1 IO availabsic Thin 200 rmiil'ed it public sewer is ast Installation will serve: Residence_ Commercial Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: SAAfD —Water table depth I 3000 No. Compartments SEPTIC TANK O Type/Mfg �' Capacity PKG. TREATMENT PLT. 0I Method of Disposal Distance to nearest: Well NIA Foundation /'� Property Line 216" k/ i LEACHING LINE No. 8 Length of lines Z Zoo f Total length/size 20 � FILTER BED O Distance io nearest: Well. n/ln Foundation 30' Property Lina 'u' �a ' SEEPAGE PITS II Depth Size �k Ir' Number Z �/�A Foundation /00 Property Line SUMPS - � lK. Distance to nearest: Well� i DISPOSAL PONDS O 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 peltormance 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 or subcontracting 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 -call for all required inspections. Complete drawing on reverse side. Signed % Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �'I1(ddfA r'I+^'z 1 Date �–f f" %3 Area CN9/4? ' fit or Grout Inspection by Date .Final Inspection by Data Additional Comments: r Applicant —Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ' 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 NFO AMOUNT DUE AMOUNT REMITTED Ca RECEIVED BY DATE PERMIT'NO. • EN 1324IREV.UA 51 -.� EN 1625 a _