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APPLICATION �� SAN �AQUIN COUNTY PUBLIC HEALTH STsRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services,./��y, ,/ Job Address X70 p7wY� ,� City /� erl4 Lot Size/Acreage Owner's Name 0 t�TILArAddress SZ5 W. y Phone - D. Address 3/ oe4eANsl • y9t79Y2- (9/G 85-yz93 Contractor cs� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION t of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private X-Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. —_ State Work Done Well Destruction �R Well Diameter � Sealing Material i Depth AA=–d-PWCWf S6.5 Depth --W.$ Filler Material L Depth wopq–d oywr,MT TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 Homo owner or licensed agent's signature certifies the following: "I certify that in the peiformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen'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 mus 1 for r e spections. Complete drawing on reverse side. Signed X / Title: A&A&V6 46W Date: /Z-!:S v FOR DEPARTMENT USE ONLY Application Accepted by U Date �– – Q Q Area T Pit or Grout Inspection by Date Final Inspection by _ Date,–3–©© Additional Comments: �rr Li r� Q r 0 tAL 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 FEE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'NO. INFO (� . EH13.24(REV.I/A5) `+'� v EH 11.20 1