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APPLICATION SAN jJAQUIN COUNTY PUBLIC HEALTH oERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 C \,Lr�'ST '� �� "� City _ Lot Size/Acreage LfkAddress V, F PhonA.qQ413 cc, Owner's Name �Yl1�C t C0►1 4,0� 4 Contractor �LCJS}�C h S'1 0.Tcl E} CAddress �' c ' UK 1�'",C'�C•rC`tl�r tATLlcense No. L 'J Phonk i w 373-`m_, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation :' "n' Dia. of Well Casing P A C l Domestic/Private ❑ Gravel Pack g Tracy Type of Casing_ NIA Specifications I'1 Public )Q Other f_1 Delta Depth of Grout Seal IC Type of Grout 10� il�vni��'- I I ImUauon L C Approx. Depth I I Eastern Surface Seal Installed by tii�S� 'f`A Sim;V- E X t'• %OcC 1 k iia Repair Work Done U Type of Pump tj H.P. ___ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth o Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify thtt 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 inapgctions. Complete drawing on reverse side. Signed X 1`C'Nt6i, L MGI:0 itle: �'G7 C �11(2.�1 uta r-1' Date: I FOR DEPARTMENT USE ONLY �- Application Accepted by / � ,� Date ��~ Area Pit or Grout Inspection by Date 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 w FEE IJ INFO AMOUNT DUE AMOUNT REMITTED CK S f INFO RECEIVED BY DATE PERMIT NO. Page I3A EH 17-24(REV.iinD11 EH 1 4.2a J i