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APPLICATION r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES Y 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. �f�G r� Job Address .530r'�K >�U - _ _ City j! "��00 Lot Size/Acreage �QjS00 !'"r y y Owner's Name K O� iQ►�1 YI �7� r71 QAddress 3�5 hlO+t f O !� SqS4 N Phone�/S` cfs3 tib Sp s��5 Myr : S_4v .1 I tY� License No.S�Phon Contractor_ Addses TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ` Monitoring Well [3r �-SFe DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION rl n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public 1-1 Other fl 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 Wor Done S Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Welt Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size n' 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 Home owner or licensed agent's signature tartifies 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." 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 must ca0 or tt;Krequifed inspections- Complete drawing on rQverse side. Signed Title: J U�`� Date: 9 FOR DEPARTMENT USE ONLY q Application Accepted by ^_1,�r F Date L Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: 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 REMITTER CK INFO CASH RECEIVED BY DATE PERMIT'NO. nage 13A • EM E3-24 trtEV,ri w SiAq EH t4-Ia ffy�V03