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y APPLICATION c SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE(209)469-3420 P O BOX 388, STOCKTON,CA 95201-0388 { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -- (Complete SSUED _,,; , . (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 Development Title Section 9-1110.3/and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. 1Vr : Job Address City ' Lot Sire/Acreage Owner's Nervef ' ix '` 6� 'S- - Address 7V"7 �� s L• Phone Contractor Lea,P-�--d l-G Address License No. Phonef � �7~�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171` OESTRUCTION"i❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 01 { OTHER-'C Moepitoring Well C3DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLO. PROP LINE li* , {� \ FOUNDATION IDS AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing la Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public '%Ocher 11 Delta Depth of Grout Seal Type of Grout I I IrnUauon �5--Approx. Depth 1K Eastern Surface Sea; Installed by' '! " Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Suing Material i Depth r Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/AODITION l I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 Ieet.1 Installation will serve: Residence — Commercial_ Other C { 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: Weil Foundation Property Line LEACHING LINE C1 No, & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 peiformance of the work for which 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 sub-contracting signature canifies 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 laves of Ca'fomia*, s The applicantu1-1-C I for wired inspections. Complete drawing on5verse side Signed X t't` �_"`{�''"C"�. Titre: r'`fit Si Date: FOR DEPARTMENT USE ONLY AIA Area.Accepted by ate Pit or Grout Inspection by Date Final In pection y Date l Additional Comments: Applicant - Return all cop4121 Pu is Health Services to: San Joaquin County Environmental Health Permit/Services ' 445 N.San Joaquin,P.D.Box 388,Stockton,CA 95201-0388 s ia0 v m cC FEE INFO AMOUNT DUE AMOUNT REMITTED (CASH RECEIV BY DATE PERMil'No. M . EN13.24(REv,1irs) / / 7 � 7 � / ( z EH 14.20 P7