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r _ _ APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICIsS ENVIRONMENTAL IiEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YM FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit :o construct and/or install the work herein aescribed. This application 1s made in compliance with Ban Joaqulrr County Ordinance No. 549 and 11362 and the Rules and Regulations of San Joaquin county�PuClic Health Services. -fir' Job Address _C fly r 9 ✓� � _ C",,�L� Lot S12e/Acre.ge _ Owner00 's Na" Address ^ _ ._d!. _.—�.__,�/_p—y_/PPhone �� COntIdClOr� J %�t�y'I �p neress P�C/._��rc�G L.cense no.!r»%�rf�_Phone w, r�� TYPE OF WELLIPUMP NEW WELL C WELL REPLACEMENT U DESTRUCTION --I Out of service Hell PUMP INSTALLATION Z SYSTEM REPAIR 0 OTHER r Monitoring Wel r, 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 O Industrial O Open Bottom I^i Manteca Dia. of Well EKcavation Dia. of Well Casing [.I DomashciPrivate ❑ Grave! Pack7 U Tracy Type of Casing_..,_ Specifications - I'l Public 1 1 Olher !I Dehe Depth of Grout Sea! Type of Grout XI I-0auon — Approx. Depth , , Eesterr, Surface Seal Instilled by Repotr Work Done ;3 Type of Pump H.P _, ., Stare Work Done_ Well Destruction C-2Well Diameter _ Sealing Material i Depth Depth Piller Material I Depth TYPE OF SEPTIC WORK. NEW INSTALLATIO% 1 REPAIRiADOIT!0N l DESTRUCTION I I INo septic system permuted it Public sewer is available within 200 feet.l (� Installation will serve: Residence _ Commercial_ Gikar Number of living units; Number of bedrooms Character of and to a death of 3 feel: table depth SEPTIC TANK ❑ Type/Mfg capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation v Property Line LEACHING LINE P No. 6 Length of lines , Total length/size fILTER BED Cl Distance to nearest: Well_ Foundatwn �..v� _ Property Line SEEPAGE PITS l I Depth _ Site _, �— —_ Number SUMPS i.1 Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS U I hereby certify that I have prepared this application and that the work wilt be clone 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, 1 shelf not employ any person in such manner as to become subpct to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applicant usI rH re ire tans. Complete drawing on reverse side_ 'Jws714 Signed •�� Title ti " — � Date: _ FOR P TMEN7 USE O Appliutlon Accepted by _ Y _ Date C Area, t• t' Pit or Grout hrapection by � Date final inspection b --QaLe Additional Comments. v`� J 6ZZd� ZZU Apt?11c:rnt - Rrturn all copies to: San Jokilut❑ County Public If.alt.h Services Environmental Health Permit/Servicer j FEE 445 N San Joaquin, x 2009, Stkn, CA 95201 l INFO AMOUNT DUE AMOUNT REMITTED ECEIVED By D E PERMIT NO. EH 14 Is 1