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APPLICATION - Jojff� "4�� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON CA 95201 C . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made•tolSan Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliadce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San F Joaquin County Public Health Services. Job Address �'/ N`� _ City Lot Size/Acreage i Owner's Name I�Y,�7�� r't f �'Yt��---- - Address... A"r r� Phone�� Contractor AddresCR L1k License TYPE OF WELL/.RUMP-I NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Ll Out of Service well ❑ "PUMP,INSTALLATiON 0 SYSTEIN'REPAIR'.O-.......----- Y OTHER O Monitoring Nell L� DISTANCE TO NEAREST;,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` 2' FOUNDATION AGRICULTURE—W-ELL— OTHER WELL' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS 11 Industrial ,❑ Open Bottom 0 Manteca Dia. of Well Excavation pia. of Well Casing C:1 Domestic/Private- b Gravel Pack ❑ Tracy, - Type of Casing_ Specifications y I l Public 4; . +l l Other" n Delta Depfh`of,Grout Seal Type of Grout 11 Ifri0ation _..ApptaK. Depth l I Eastern Surface Seal Installed by ` Repair Work Done L7 Type of Pump H,P, t - State Work Done Well Destruction ❑ Well Diameter f` Sealing Maerial:.da Depth - Depth f Filler Material do Depth Y TYPE OF SEPTIC OAK: NEW INSTALLATION I 1 REPAIR/ADDITION'" DESTRUCTION I I INo septic system permitted if public sewer is 9 available within 200 feet.) Installation will serve: Residence Commercia Number of living units: Number of bedrooms y L Character of soil io a depth of.3 feet: t� Water table depth f SEPTIC TANK L51!!Z-_ ❑ Type/Mfg rrf2_#215 �AhK Capacity No. Compartments PKG. TREATMENT PLT. ❑ r :. Method of Dispos�l Distance to nearest: Well &j!2 Foundation NZ - Property Line �- LEACHING LINE FE�b X Na. 8 Length of ilnes /-,)WA�l Total length/size FILTER BED C) Distance to nearest: Well jQ _ Foundation 2S Property Line _ZI _ 4 SEEPAGE PITS 11 Depth Size Number SUMPS �4, Distance to nearest: Well Af22 Foundation�_ Property Line DISPOSAL PONDS ❑ x I hereby certify that I have prepared this application-afid"chat the work will-be doiie:in:ac'cordance=wiih=San-Joaquin county ordinances, state laws, an 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 no employ p y an y 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." P i The applicant muicelll for alb r ire ins tions.,Compl " drawing on reverse side. Signed.X `��4 Title: Date: t F R DEPARTMENT USE ONLY Application Accepted by 1 ...� h.�,2A,,*;3L0k-0 4 .Date-- - - - - .2 as Pit or Grout inspection by I Date Final Inspection b Dated Additional Comments: - 11 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 REMITTEDT CK RECEIVED BY 9ATE PERMIT'NO. . EH 1241AEV,v/M 51 EH 14.a2e f �/a t„�y�.—./