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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 t'r P O 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. / ,� t �, �,�, Job Address _ g4 I-LAA City�1Llt� Lot Size/Acreage Owner's Name _ u�T�J_7L'F`2T'yA_AJ_ dress Phone Contractorl/VAddress nse No. phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ r- 1 SYSTEM REPAIR 0 OTHER 0 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, DISPOSAL FLD_ t PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 1 CONSTRUCTION SPECIFICATIONS _ n Industrial ❑ Open Bottom ❑ Manteca --Dia. of Wail Excavation Dia. of Well Casing • r Ca Domestic/Private ❑ Gravel Pack ❑ Tracy r Type of Casing_. Specifications 1 1'I Public Cl Other fl Delta i E.,Dapth of Grout Seal Type of Grout ! Ul t I Irrigation _ Appr6x.Depth I I Eastern ` Surface Seat Installed by I ' G' Repair Work Done L7 Type of Pump H.P.J - ---f # State Work Done Well Destruction ❑' Well Diameter s Sealing Material 6 Depth l j i Depth + Filler Materiel A Depth t f TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I C17B. TRUCTION I ! dNo septic system permitted if..putilic.sawer.is available within 200 feet.) 1 Installation will serve: Residence Commercial Other- the_r + I ) Number of living units: Number of bed ooms # j ! Character of soil to a Qepth of 3 feet: Water table depth SEPTIC TANK. s ❑ Type/Mfg $ r Capacity No. Compartments } PKG. TREATMENT PLT. 0 � � I Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE j L1 No. & Length of lines _ Total length/size ` FILTER BED n Distance to nearest: Well Founaabon Property Line SEEPAGE PIT ` 1 epth Size Number f A SUMPS istance to nearest': Well Foundation J Property Line DISPOSAL PON 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` Horne 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 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 compenss- f Callfor . he applicaJus call rZaLd cti ns plate drawing on r rse Sidi. SCS Sign Title: <- - Date: +� OR DEPARTMENTSE 0 LY � r' Application Accepted by - t Date T7�" a ' E Pit or Grout Inspection by J I D'ate' inai inspection by to Additional Comments: Applicant - Return all copies�to:-ASan,.Joaguin-Cou ty public Health Services • r Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009; Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA$H RECEIVED SY DATE PERMIT'NO. • EH13.14{REV.t/nS1 ,�a ` D .L�� :3 ,� � q3--�� 7 EH i4.1a