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A APPLICATION SANOAQUIN COUNTY PUBLIC HEALTHERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (2091468-3420 P O BOX 2009, STOCKTON, CA-95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j Application is hereby tsade,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 amd Regulations of San Joaquin County Public Health Services, Job Address _:L� }■ a _ Q C1 �( L .V2 - City S7LOCNG Lot Size/Acreage Owner's Name 4 Address 2 Oo 0 a4cow Cf�I�yDh ��• yo0 Phone jj�� ,� x-7'7 ,/,''�+'l �Lornten �`1Sas � ContraclorT�LYI/itil @ SI"C Address_LL-L�7F �� 26 . License No. �Q Phone la&2S� TYPE OF WELL/PUMP: NEW WELL ❑ , WELL REPLACEMENT F1 DESTRUCTION PK Out of service Well, PUMP INSTALLATI N ❑ SYST M REPAIR ❑ '91,HER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 4_ SEWER LINES �— DISPOSAL FLD� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing C1 Domesticl Private ❑ Gravel Pack • ❑ Tracy Type of Casing_ Specifications f'1 Public f'1 Other f1 Delta Depth.of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done O Type of Pump N.P. State Work Done — Well Destruction © Weil Diameter Sealing Material 3 Depth Depth Filler Material i Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAiRlADDITION Irl DESTRUCTION I I (No septic system permitted if public sewer is available within 100 feet.) n Installation will serve: Residence— Commercial— Other C Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t i x f LEACHING LINE C1 No. & Length of lines Total length/size l FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS it Depth Size Number ! SUMPS Lt Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will ba,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 subcontracting 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- tion laws of California." The applican must c ll f r iI ired inspgctions. Complete drawing o verse side. / G t Signed Title: �S/ ! -- - -- Date: 1 FOR DEPARTMENT USE ONLY Application Accepted by Date 41 Area ., Pit -Grout l spection by Date �4.� 'Final Inspectiionby Date �'Additional Comments: . � �'l' Applicant - Return all copies to: San Joaquin County Public Hth Services Environmental Health Permit/ ervices 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED RY DATt PERMIT'N0. INFO ,vh • EX Q-24 IREV.1l N SI 1 -63.900 /f�d'r- •� �� r_ "�'lJ EM 1445