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APPLICATION SAN JOAQUIN COUNTY PUBLIC ER CES ENVIRONMENTAL HEALTH, D 445 N SAN JOAQUIN, PHONE i( -3420 J P O BOX 2009, STOCKTON', PERMIT EXPIRES 1 YEAR FROM ` (Complete in Triplicat �- Application is hereby made.to San Joaquin County for a permit to construct and/o a 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 ¢3S/ S/��0J, Wl- � cay 400 Lot Size/Acreage TO _ Owner's Name AA vpy �� Address/, L�.�1_ [ Phone?� f Contractor AJ4 _ M12&R& Address e&Q 166 4497-M01111" JW License No" Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT it DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION C SYSTEM REPAIR _ OTHER O Monitoring Well 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 C7 Industrial ❑ Open Bottom �, Manteca Dia. of Well Excavation Dia. of Well Casing C 1 Domestic/Private O Gravel Pack f.� Tracy Type of Casing- -_ Specifications I'1 Public Ia Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done () Type of Pump H.P. _—_ State Work Done _ {� Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material 4 Depth (P TYPE OF SEPTIC WORK: NEW INSTALLATION ' 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is ter,, available within 200 feet.) Installation will serve: Residence _ Commercial _ Omer"zt. Pa �TS M5-X13--7600-51- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth n SEPTIC TANK 0 Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well . Foundation Property Line �1 LEACHING LINE 0 No. 8 Length of lines _ Total length/size �F FILTER BED n Distance to nearest: Well _ Founoatron Property Line SEEPAGE PITS 11 Depth Size Number _ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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 subcontracting 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 ust call 0or :;1I�quired ctions. Complete drawing on reverse side. Signed X Title: , Aqp sr- w6a Date: FOR DEPARTMENT USE ONLY 1j Application Accepted by — Date ` Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: t✓ S . O�sti U 4' Applicant - Return all copies to: San Joaquin Cou ublic Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO EEE AMOUNT DUE AMOUNT REMITTED CASHCK RECEIVED BY DATE PERMIT'NO. EM 13.24IREV.r/A5r 35 C 1. / g 7� EH 11.20 ,_