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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. 544 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address / 15' yAQAoC Y '.Al __ City Le Lot Size/Acreage x s Owner's NamerS O Address (xz a-�- E •�A2 _.t1EY _/.A/ Dp/ Phone Contractor d c) Adress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Fi_D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications q, I'} Public l-1 Other ❑ Delta Depth of Grout Seal Type of Grout (- I I Irrigation —Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Welt Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION I I DESTRUCTION t I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceZ Commercial— Other Number of living units: _/_ Number of bedrooms Character of soil to a depth of 3 feet: Z'AA)D I/ 1 414rvt Water table depth SEPTIC TANK ❑ Type/Mfg P d-L_ Capacity-2y,00 No. Compartments Z PKG. TREATMENT PLT. ❑ pr Method of Disposal Distance to nearest: Well 2:S0 Foundation a Property Line LEACHING LINE No. A Length of lines — loci Total length/size FILTER BED n Distance to nearest: Well a 50 Foundation ie Property Line _ SEEPAGE PITS I'i Depth IZ' Size yX t 7- Number SUMPS XI Distance to nearest: Well r:Sd r Foundation 9®r Property Line DISPOSAL PONDS o 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 _ 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 manna(as to become subject to workmen's compensation taws 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 ail required in ti s. Complete drawing on reverse side. Signed Title: [i zt, _ Date: FOR DEPA TMENT USE ONLY r Applic ion Accepted by �— Date Area r�o6t fn4ction by al�_ ata Final Inspection by Date, Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DAMOU[�N�T/REMITTED C K H RECEIVED BY / DATE PEERyMWN'O. M 14 + E .E(REV.r,n 5� �t y.0 -{ E U