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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 1s made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health ServicesJob Address I I_ � LL6ACrQiAd n• �� w — City Lot Size/Acreage r'sName L,4F"e dress xy*'Y� _— PhoneLQ r�,4, ��a for tA#A"1q&es UV License No, v t[/ Phone �vl� TYPE OF WELL/PUMP: NE ELL ❑ WELL REPLAEtMENT F1 DESTRUCTION L-) outof Service well Ll PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationV-15 _ Dia. of Well Casing omestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_. Specifications I"I Public f-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I astern Surface Seal Installed by Repair Work Done U Type of Pump H.P. Z State Work Don ! Well Destruction .. CI -,Well Material & Depth•Well Diameter �— e Depth Filler Material & Depth TYPE OF SEPTIC,WORK: -NEW INSTAL TION I I REPAIRIAODITION i I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of b,�drooms Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 9 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that,_] 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 perion 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 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." t The applic ust ca I requi ed inspections. Complete drawing on 14orse std � Signed Title: Date: 1r 61qz, O DEPARZM.ENT USE ONLY ry Application Accepted by &f)LA j y Date Area 0 f, Pit or Grout Inspection by Date Final Inspection by Data �~ 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 AMOUNT DUE AMOUNT REMITTED RECEIVED RECEIVED BY DATE PERM17'Np. INFO �J', . EN 13.241REV.1/NSk �� r�� /' M IEH file