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APPLICATION;' jl ,l SAIlS..,DAQUIN COUNTY PUBLIC HEAI,TgERVICES' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE:: (209)468-3420 I� P O BOX 2009, STOCKTON, CA 95201 li PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ' (Complete in Triplicate) j 11 Application is hereby made to San Joaquin County for a permit to construct and/or install the rrork herein described. This application is madelin cotsplisace vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. :i f Job Address _d fZy Al AV-192,q-X7— City �+rc�.+!� Lot Size/Acreage Owner's Name 12"111 Address Phone ? Contractor p)J!^s Address SLr✓1/!S-e Z,61d Gi. dl License No, /c z]z4. Phone 2Z-11a-7vse TYPE OF WELL/PUMP:, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION o t of Service Well (q, '• PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 'p I f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE . n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial a ❑ Open Bottom 0 Manteca Dia. of Weil Excavation Dia. of Well Casing C F n Domestic/Private ? Ll Gravel Pack 0 TracyType of' ''Casing- Specifications I'I Public 1=1 Other n Delta Depth of Grout Seal Type of Grout I I i Irrigation Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done 0'Type of Pump �_ H.P. State Work Done T. ' Well Destruction t-` Well Diameter Sealing Material & Depth 6 ! Depth r Filler Material & Depth I TYPE OF SEPTIC WORK; NEW INS ALLATION I I REPAIRIADDITION t I DESTRUCTION l I (No septic system permitted it public sewer is available within 206 feet.I Installation will serve:: Residence` Commercial— Other ! Number of living units` Number of bedrooms I� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method ofDisposal ! Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No.& Length of lines Total length/size I ii FILTER BED i❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS �Cl Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS i❑ i 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 .j employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's ihiring or sub-contracting signature certifies the following: "I ertify 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 appiica ust r aired inspections. Complete drawing on reverse side. � E: Signed Title �' J Date: Z-2 �" � I c/. FOR DEPARTMENT USE ONLY Application Accepted byl r ' Data /`� Area j { Pit or Grout Inspection by Date a Final inspection by Date i1 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services i Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2069, Stkn, CA 95201 't J FEE INFO AMOUNT DUE AMOUNT REMITTED CCII ABFI RECEIVED BY DATE PERMIT'NO.A11-1, . EH t 3.2401EV.11asii �(✓r�- Cl/L.J�- EH 142E f .F L` ']