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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) l Application is hereby made.t;o Ban Joaquin County for a permit to construct and/or install the work herein described. This I application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of an J Joaquin County Public Health Services. LarO". t Job Address 10736 � L[ W6et' City Lot Size/Acreage Owner's Name /%04* 412 Address Z 0 73 A', rT' +✓ Phone 1(44 ' d f kConiractor / Address 'r7�7%r° �� License Nofi�Zd Phone 7_23?� TYPE OF WELLIPUMP: NEW WELL ❑ LL REPLACEMENT . DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLAT) N ❑1c SYSTEM REP 11R C7 OT_HEB ❑ Monitoring;ell C7 DISTANCE TO NEAREST: SEPTIC TANK U SEWER LINES ISO DISPOSAL FLDAt1 PROP. LINE FOUNDATION �� AGRICULTURE WELL _f S - OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATION C] Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing v" 4f Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'1 Public Ei Other fl Delta Depth of Grout Seal t�OFr� T pe f GJ I i Irrigation �,Approx. Depth 1 1 Eastern Surface Seal Installed by Jf Repair Work Done U Type of Pump H.P. State Work lone_ Well Destruction ,Ll Weil Diameter Sealing Material.i Depth- T' epth- Depth filler Material & Depth l : PE OF SEPTIC WORK; NEW INSTALLATIO I REPAIR/ADDITION I i DESTRUCTION l I (No septic system permitted it public sewer is e.Tat 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 i SEPTIC TANK ❑ Type/Mfg apacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wellundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size y' FILTER BED fl Distance to nearest: We Foundation _ Property Line SEEPAGE PITS It Depth Sizembar SUMPS LI Distance to nears Weil , Foundation Property Line DISPOSAL PONDS f l I hereby certify that I have prepared tfli pplication 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 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." The applicant must call for all required` pections. Complete drawing on reverse side. I signed >=0 Title: to Date: C LFO EPARTMENT USE ONLY Accepted by ^� Date�b� � Area Pit or Gro 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 O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT RTM1T7ED (��A$H R/�E�jC�EIVED 6Y DATEq GPERMI7�'NO�. . EH1 -211NEV.Iin5i t„ EH 114-2e tN