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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C SNS-�ftv 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 'QJ ,PLS Job Address -�r+�S klN�O/ _ _ City—L0dLot Size/Acreage c Owner's Name T7E.�J�iE7f��>E.-J Address 36� / 1�/J 121 Phone 34J-16 �5 C_ob I Contractor �' Address _ _ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION I-) out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER 70 M nitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ G INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing C I Domestic/Private Cl Gravel Pack n Tracy Type of Casing_ Specifications FI Public ( I Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrillation __ 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 i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is V o. available within 200 feet.) W Installation will se Residence _ Commercial_ Other Number of living units: Number of bedrooms `r Character of soil to a depth of 3 fee . "tiC/ater table depth SEPTIC TANK O Type/Mfg _ Capacity✓ " No. Compartments PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foun Property Line LEACHING LINE L1 No. b Length of lines' " _ Total leng e FILTER BED Ll Distance to ndarest: Well _ Foundation Property Line O SEEPAGE PITS A 1,Depth Sire _ Number SUMPS / I_I Distance to nearest: Well_ Foundation Property Line DISPOSAL PONDS O I hereby cenify that 1 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: "1 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- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY 4ke Application Accepted by ;ZA _ DateArea `-2/ 110, , 4wPit or Grout Inspection by Date �Final Inspection by ' G ate Additional Comments: (",ecus C17AAlI C77CJ fiAi4/e— ." 92 —/Oz C„oc�� ['r Arc 1rLs� Q([ssa rwal�Car �.c Applicnnt - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services lfy�re2(�, 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE } / INFO AMOUNT DUE AMOUNT REMITTED C`6AS11� RECEIVED BY DATE PERMIT'NO. �r�► EH 17 N INEV,r i n s) � /V LTV EH C f s• u.2e