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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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. f '_'I,j Job Address 01 '-N o4 4�. ret4 City��^�'� Lot Size/Acreage Owner's Name e Gr R(4I �1AGI Address SAAi 6 Phone Contractor 17 (1 Df411lK Address 3 WAld License No.oqql -1 G(84 hone /6 436}t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS///SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 54, .01.(it P ,S -W► L) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [-I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'1 Public P60ther 5A1 SW-A3 11 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ State War 07s _ Well Destruction ❑ Well Diameter Sealing Material & Depth exp+ Depth A)oV fig Filler Material & Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (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 dopth 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 0 No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 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 tho following: "I certify that in the performance of the work for which this permit is issued, I shall employ portions subject to workman's compensa- tion laws of California." The applicant ust call for all required inspections. Complete drawing on reverse side. 'a Signed Title: PFJ _ ('0!5 Date: OR DEPARTMENT USE ONLY Application Accepted by Date ),' ,� f �j t+ Pit or Grout Intpoction by Date V- [ � Final Inspection by �ttOato 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 tEEINFO CK 0 AMOUNT DUE AMOUNT REMITTED If CASH RECEIVED BY DATE PERMIT•NO. Jt^„ ,,,, 2� f Page 13A . EM 13-24 IREV.r/est �YIJII. EM 14•Ie