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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH S,AVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 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. Job Address �/ L�� —�!/ City _ Lot Size/Acreage Owner's Name-n4//QJ-, Ah ` Phone Contractor' Address � �) ta cense No. Phone p TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION O Out of Service Well PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� t C] Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing �J1I C] Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications \� ('I Public [-I Other n Delta Depth of Grout Seal Type of Grout 11 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. -- State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION ESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) ` Installation will serve: Residence Commercial�r Number of living units: � Nu ter of bedr ms Character of soil to a depth of 3 feet: L�� 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 97 LEACHING LINE L� & Length of lines Topl length/size FILTER BED ❑ Distance to nearest: Well Founaation 3-s Property Line SEEPAGE PITS Ik,;- fTepth ' Size Number SUMPS LI Distance to nearest: Well I Foundation Property Line DISPOSAL PONDS O 1 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 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- te California." The applican m t all f all req it ins c io plate rawing reverse siF1e. Signe Title: �.E`� \l Date: cam- er� FOR TM ENT USE ONLY Application Accepted by 9,. Date' — Area L Pit or Grout Inspection by Date Final Inspection by Date 7 Additional Comments: d -17,,01 /h'A e /✓ICK ;V6 - 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH ECEIVED BY D TE PERMIT NO. e L4� EH 13-24 IREV.ri KSr C fJCvEH 14-2e w1L ^ �1a