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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH4g6VICES ENVIRONMENTAL HEALTH DIVISION N, PHONE (209)468-3420 3 r t , STOCKTON, CA q 5 �D y 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. Qq Job Address 00 ;4Q �� ` y City�+ Lot Size/Acreage ) �7 S,,U l� Address [} . UZt" z9 atJ Phone Owner's Name �-1, Contractor (I• Address � O01� IIf104_qp i ��Ot"�_nse No. eOJJ'��t� Phone(r SJ01i3ISM TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 1893 SEWER LINES _1130) DISPOSAL FLD._r1?4 _ PROP. LINE'a_'�L-6 r ` �,ttt P1J� �� SC}f�e� fOUNDATION AGRICULTURE WELL OTHER WELL _- - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dpr,W- L7 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of WialL FI Domestic/Private ❑ Gravel Pack00 0 Tracy Type of Casing_ — Specifications UI Public '6 Other:Soy� &Nkt Cl Delta Depth of Grout Seal F, it p Type of Grout)a w 6ke"rt I I Irrigation Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done U Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material i 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: Well Foundation Propeny Line LEACHING LINE ❑ 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 cenify 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 cenify that in the perlormance 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 fogowing: "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." 1 ,Il The applicant at call r I r wired inspections. Complete drawing on reverse side. (� i��r� 3;-qP1 Wlq j ,v Signed _ Title: v - ref)W4_Rk Date: —41 Zq FOR DEPARTMENT USE ONLY Application Accepted by _ S�tILUUfX/Yv NU^^r� _ Date "S Area Pit or Grout Inspection by Date Final Inspection by Data Additionsf Comments: Applicant - Return all copies to: San Joaquin County Public Health Services C-le4tfi Environmental Health Permit/Services _ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 OIL W)/ 4�% ��W1'� ✓YLL k FEE ICK ff INE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY c�DATE PERMIT'NO. Page r3A . EH t3-?4 IREV,1in51JV /J rf,,(� J [ EH S♦-76 fj;f -✓ -1 024