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APPLICATION FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT MWIRES 1 YEAR FROM DQE 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 application 1a made In cottgtllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 111e; O /7'� • � �� City / k 111 Lot yi ze/Acreage / V c Owner's Name -7_/ / /L'1 V� t%� Address Phone Contractor 1*001W6% "(dress 4(�t/wLicense No. Phone.C�L TYPE OF WELL/ Fe WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 SEWER LINES DISPOSAL FLO. PROP. LINE AGRICULTURE WELL Jos OTHER WELLif-PITS/SUMPS PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation 1 pia. of Well C ❑ Tracy Type of Casing_ 9 Specifications n Delta Depth of Grout Seal 1/5'rType of Grout I I Eastern Surface Seal installed by -102.0 H. P. State Work Done _ Sealing Material i Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I fNo 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 top 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. & Length of lines Total length/size. FILTER BED E:I Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth —Size Number SUMPS LI Distance to nearest: Well _ Foundation _ Property Line DISPOSAL PONDS L1 'w ' r 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 Sen 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 workmen's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call pal squired inspaptions. Complete drawing on r v se side. Signed // Application Accepted by Pitfro— ut I pectbn by — Additional Comments: Applicant - Return all copies to: • EH 1321 IREV, i i n s EH 14.25 r e Is R DEPARTMENT USE ONLY Data _3 'Area n 14 - Date Final Inspection by — Data �- San Joaquin County Public ifealth"Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INF PUMP INSTALLAT DISTANCE TO NEAREST: SEPTIC TANK 4e AAs/ FOUNDATION INTENDED USE TYPE OF WELL n Industrial Cl Open Bottom )QDomestic/Private ❑ Gravel Pack I'1 Public f7 Other x1trigation _ Approx. Depth Repair Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter _ Depth Fe WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 SEWER LINES DISPOSAL FLO. PROP. LINE AGRICULTURE WELL Jos OTHER WELLif-PITS/SUMPS PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation 1 pia. of Well C ❑ Tracy Type of Casing_ 9 Specifications n Delta Depth of Grout Seal 1/5'rType of Grout I I Eastern Surface Seal installed by -102.0 H. P. State Work Done _ Sealing Material i Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I fNo 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 top 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. & Length of lines Total length/size. FILTER BED E:I Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth —Size Number SUMPS LI Distance to nearest: Well _ Foundation _ Property Line DISPOSAL PONDS L1 'w ' r 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 Sen 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 workmen's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call pal squired inspaptions. Complete drawing on r v se side. Signed // Application Accepted by Pitfro— ut I pectbn by — Additional Comments: Applicant - Return all copies to: • EH 1321 IREV, i i n s EH 14.25 r e Is R DEPARTMENT USE ONLY Data _3 'Area n 14 - Date Final Inspection by — Data �- San Joaquin County Public ifealth"Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INF AMOUNT DtIE AMOUNT REMI EO AAs/ ECEIVED BY DATE PERMIT' NO. t 13 `o o 4 %t O II/