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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTh SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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. 5L9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address !�/1 �n U _ City��G� Lot Size/Acreage _ V90-c - -(-c,,b. Go. offIt/8j- Owner's Name`S I_L \ �- e-C ri `p0 L �r (-Address Q _J!A. P C Cl^ Phone - v z.J� G0' `1_C•GG Contractor a i Address��` _ �_L„e_nIbO._Cfj O< License No. Phone _�t llL --iI % 2 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT C1 DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATIONn G SYSTEM REPAIR Ll OTHER ❑ Monitoring Well �7 DISTANCE TO NEAREST: SEPTIC TANK lL`� SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation` 10- s rfCAc_> Dia. of Well Casing 1� C I Domestic/Private ❑ Gravel Pack 117 Tracy Type of Casing �4S�t,yo Specificatons O rl I'1 Public 1.1 Other I1 Delta Depth of Grout Seal Type of routC M C,�� T I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump a, Qbre-fi M P. %z 14 P St is Work Done _ V)/ell Destruction O Well Diameter A+ r r)Gk Sealing Material & Depth Depth, Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 210 feet.) Installation will serve: Residence _ Commercial __ Other _ Number of living units: Number of bedrooms M Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El Met EN Distance to nearest: Well Foundation PropertyATCOVED {�\ LEACHING LINE 0 No. & Length of lines _ Total length/size _1i 5 FILTER BED Cl Distance to nearest: Well Foundation _ Proper'Al19 ugTy v�I POi;6FG„TF-AtF-Hvi�E� SEEPAGE PITS 11 Depth _ Size _ Number ENVIRnNA1FNinl ur-'A' ru n%lrjSION SUMPS 1.1 Distance to nearest: Well Foundation ____ Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be dune 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 blect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follo g: "I ce y that the pert ante of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws o Ifo ie." The ap t c IL r al ui ins ti s. mplet'adrawing on reverse side. �3 Sig �� '74 Title: Date: FOR DEPARTMENT USE ONLY pos Application Accepted by Data / L Area Pit or Grout Inspection by Date - _�13��//�F,innaal In�sppection by Date dditional Comments: !l/ C Applicant - Return all copies to: San Jon in County Public health Services Z��/ �/� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009„Stkn, CA 95201 U frP. s INFO AMOUNT DUE AMOUNT REMI`T/TrED / CAS N RECEIVED BY �J DATE PERMIT N0. E 1124 IAEV,iinsi EHH 14 26 .l