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APPL I CATION SAN IAQUIN COUNTY PUBLIC! HEALTH,' 'TRVICES ;, ENVIRONMENTAL HEALTH DIVIS 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCXTON, CA 95201 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUID fi (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or install the,,vork herein described. This application is made in Conpliance with San Joaquin County Ordinance No. Joaquin County Public Health Services. 51+9 and 1862 and the Rules and Regulations of San Job Address 2-2,J Ciryr_ �OA� Lot S12elAcreage ¢_� ci.-f/�G.•� E� Owner's Name 1120,qriv-A . — Address �Phone jJn/I9a •� •71;tr: Contractor Address !r S s_ ell ,/ ( � �i' License ffo.��)"4'42��L phone !G JrS�"7yi TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑, OTHER 0 Monitoring Well EI DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES n DISPOSAL FLO. l PROP. LINE FOUNDATION AGRICULTURE WELL 'F OTHER WELL i PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �i" {pia. of Well Casing 2 h 11 Domestic/Private 11 Gravel Pack L7 Tracy Type of Casing c- T r YP 9 Specifications V] Public ('1 Other n Delta Depth of Grout Seal --�� r�3�' ',Type of Grout _e-- {_ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump N.P. State Work Done _ + Well Destruction 0 Well Diameter Sealing Material & Depth � _!1c3y.y..•�sr_ s•;:_I Ii Depth r Filler Material i Depth it 2- TYPE TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITiON I ! DESTRUCTION I I (No septic system permitted if public'sewer is k i available within 200 feet.I, i Installation will serve: Residence_ Commercial _ Other N Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK 0 Type/Mfg Capacity' No. Compartments PKG. TREATMENT PLT. ❑ " 'y `i l�r�<FiAethod of:Disposal " €; Distance to nearest: Well .Foundation_.'S y =Property-Line it y r a T. LEACHING LINE C1 No. B Length of fines �':�Jdtal length/size I FILTER BED ❑ Distance to nearest. Well Foundation.- T:prq ieity dine I II ray— :r _ SEEPAGE PITS 11 Depth Size _Nunibtir SUMPS LI Distance to nearest: Well Foundation Property tine I1 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 Wl Iich this permit is issued, I shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sut>-contracting signature II 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 applica t c or off required inspections. Complete drawing on reverse side. l' Signed Title: Date: ' 4 i; FOR DEPARTMENT USE ONLY j Application Accepted by ` 22 Date �a i Area, l r' ZJ Pit or Grout Inspection by ` Date Final Inspection by """ Date Additional Comments: - s Applicant - Return all-copies to: Sari Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box .2009, Stkn, CA 95201 FEE e ! ; INFO AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE i PERMIT'NO. 1�EI E . EH 13.24(REV. H141a ` L } t I . ii.