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APPLICATION ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, -STOCBTON, 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 vork herein described. This ap�icatio�Ger liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations f San Joaquin Co �Cffu1TT�,1111 c lth Services. / C Job Address ^ `r' _xl City Lot Size/Acreage /L r Owner's Name / r�- v Address e �U /�` Phone T2� Contractor 1/`�+ ' «D C7�SS Address �' `ter License Nol?7*7` '� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION '�PJ'::� SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L� DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD.-ISO PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing domestic/Private Gravel Pack L1 Tracy Type of Casing_ /dye Specifications Y 010 I'1 Public rt / I.1 Other n Delta Depth of Grout Seal 1..�7� )10Type of Grout I I Irrigation ��fl3da Approx. Depth I I Eastern Surface Seal Instilled by cclii4-7A- Repair Work Done U Type of Pump S(Z H.P. 3 .__ State Work Done RCDP Well Destruction ❑ Well Diameter Sealing Material i Depth L-1 Depth Filler Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if 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 ❑ No. b Length of lines Total Iength/.size FILTER BED ❑ Distance to nearest: Well Founaation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 1 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 jaws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this perrrM is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call 811 r u ed inspections. Complete drawing on reverse side. Signed X� Title: ��i✓��x Date: ,Ay- DEPARTMENT USE ONLY � 1 Application Accepted by 0�� ^'` ' Date Area w Pit o Grou spection by Date Final Inspection by Dat f Additional Comments: qua : an r / Applicant - Return all copies too q in unty Public Health Services -'////f3 ��Gk�.t�ts*. �H�/.� /,J 4. f 445iNSan onPermit Joaquin, P 0 Box 2009, CA 95201 I/ c�ul�c.-J-�azr e.• *I,Ff�/F.QEQ AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE 12-3 PEEN 13.24Iit1EV.1/ sr _ EH 14.26 \ l