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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 r P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate} Application is hereby mads to SanlJoaquin County for a permit to construct and/or install the work her 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. xJob Address City Lot Size/Acreage Owner's Name Address Phone K � yA 1 Address 2,/&* License No. 6 171 '11 ._Phone Contractor�✓ �'t! YPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of service Well gW PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial 0 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public I:) Other VI n Delta Depth of GroutSealType of Grout I I Inil]ation _ Approxi:Depth I I Eastern Seul*Ins taller derby ' Stat Well Work Done _ Repair Work Donees L] Type of Pump H.P. _ Wall Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I;I, REPAIR/ADDITION 1,1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence—I 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 Distances to nearest: Well Foundation Property Line .4 . . ' LEACHING LINE ❑ Na. & Lengtfi of lines Total length/size li FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth { Site Number Q. SUMPS U Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ J 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 iignasure cenifies 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 mannar as t6 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 iaws`of California." 11 The applicant must call for all required inspections. Complete drawing on reverse side. U[Signed f Title: Date:f v ".r F DEPA LY" ' J Applicatiori'Accepted by Data a fP . Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ' Applicant - Return all copies to: San Joaquin County'Public Health Services r {: Environmental Health Permit/Services , 445 N San Joaquin, P O Box 2008, Stkn, CA 95201 i y FEE AMOUNT DUE!' AMOUNT REMITTED RECEIVED BY DATE PERMI7'NO. r , I INFO . EH 13.24(REV.rin5) . �Q -rQC7 Ile s� r01� d 4 EH 14.2a