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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES L 1 � ENVIRONMENTAL HEALTH DIVISION a 445 N SAN JOAQUIN,PHONE(209)469-3420 0 .� 4 P O BOX 388,STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. (� �r (IIS i' Job Address ` 1'v • ee#-5 f �� City '5� ��' Lot Size/Acree,ge ' Owner's Name' 1 l�C ��s5 Address 7L17 N• f C 5� Phone q46— ` -7 Cont(actor �� l t Address �I g er License No. r Phonef TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER h tpitoring Yll ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, r PROP. LINE � � FOUNDATION _Joy AGRICULTURE WELL OTHER WELL _- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S i 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing Cl Domestic/Private I-) Gravel Pack ❑ Tracy Type of Casing_ Specifications Z I'I Public '%Other 171 Detta Depth of Grout Seal Type of Grout l I I Irrigation ,-Approx. Depth -�<Eastem Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done r Well Destruction ❑ Well 3elli Diameter ng Material i Depth Depth _ Filler Material i Depth _ d&/—I/"- TYPE /£TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION I I (No 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 Vv PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation �'Property Line t LEACHING LINE Cl No. A Length of lines Total length/size , FILTER BED In Distance to nearest: Well Founastion Property Line SEEPAGE PITS 11 Depth Size Number - SUMPS Ll Distance to nearest: Well Foundation- Property Line I \ DISPOSAL PONDS ❑ e 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 fi> 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 employ any person in such manner as to become subject to workman's compensation lava 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 shalt employ persons subject to workman's compensa- tion laws of Ca'fornia." i. The applicant asst 11 for aired inspections. Complete drawing on arse sid ' Signed Title: �'`�'t5✓ Date: -_ - FOR DEPARTMENT USE ONLY /� Application Accepted by Date MAP Pit or Grout Inspection by Date Final In petition y + ate // 4.fr-- Additionsil Comments: Applicant - Return all cop4a. to: San Joaquin County Pu is Health Services is t Environmental Health Permit/Services I 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 m FEE CK T � I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIvD BY DATE PERMIT-NO, _m 4 • EK 13-24 IREV. i h 51 — to /I 2 EK u-zA