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APPLICATION LOY-/ SAN J uAQ U 1 N COUNTY PUBLIC HE HIiii CCCDDD555 ENVIRONMENTAL HEALTH DI # 445 N SAN JOAQUIN, PHONE (20 342 P 0 BOX 2009, STOCKTON, C6011T PERMIT EXPIRES 1 YEAR FROM D ED (Complete in Triplica Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein 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. Job Address 1e_ AAk-117-`i Rcl7ci`' 5• AW.9 qty Lot Size/Acreage Owner's Name ,/ / AQ L1J Q0(Q Address l O ,` `' `Of AJL10r Phone ".GLha j�h /C Ll Address 524 L lulk ��icenst No. �ZC�c4� Phone-?,57_e)( 2- 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT l; DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR L OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , Cl Industrial C] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack U) Tracy Type of Casing_ _ Specifications I'1 Public f'. Other (l Delta Depth of Grout Seal Type of Grout � I I Irrigation ___ App(ox. Depth I I Eastern Surface Seal Installed by Repair Work Done L Type of Pump N P. ___ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth 1 TYPE OF SEPTIC WORK. NEW INSTALLATION ' I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial -- Omer 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. ❑ 1/' r _5 � ��i - ^8 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. 8 Length of lines Total length/size FILTER BED C) Distance to nearest: Well _ Founaauon Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 applicantmustcall for all repuired inspections. Complete drawing on reverse side. / 7 Signed X ✓ r / �'< Title: �ll-Z IE-1-2 r� Date: T5L 6 FOR DEPARTMENT USE ONLY 2 Application Accepted by _ Date Area Pit or Grout Inspection by Date Final Inspection by Date ii I /L V ' 1/ ,L /_ / oL L Additions'QomF+Sen� +! /"'�/� S` Pa- 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 J INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 13-24 IREV,I/A 51 ✓�.0-0 ,X✓N. cc) -73 / EH 11.20