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t APPLICATION � d SAN JOAQUIN COUNTY PUBLIC iFUAftMSSUED ENVIRONMENTAL HEALTH 445 N SAN JOAQUIN, PHONE P O BOX 2009, STOCKTON1SPERMIT EXPIRES 1 YEAR FRO (Complete in TriplgCate Application is hereby made,to San Joaquin County for a permit Lo construct �dd+/�r A, Nwo hetei described. Thib application is made In compliance with San Joaquin County Ordinance No. 549 and- f San Joaquin County Public Health Services. 4 Job Address ,`t pI�Ile IZCPID — _ C ty !E)I(YL](_4-_t_ Lot Size/Acreage Owner's Name �, NV�� C1' . ':-+ `+ ` M Address -- ��{L �— _1 -45— Phone rrA"r L, '�vt lC C c1g1L b fj►k1FfP_- _ 042 1!A; Address License No.��:J ��Phone Contractor -_------K:_/�_-- __-- — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well n PUMP INSTALLATION ❑ SYSTEM REPAIR ( I OTHER X, Monitoring Well C7 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 P6ao- , o rtbf Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavalion.___ Dia. of Well Casing [I Domestic/Private D Gravel Pack L] Tracy Type of Casing Specifications [A Public 11 Other I 1 Delta Depth of Giout Sual _ _— Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal In.%wIlud by Repair Work Done Ll Type of Pump H.P. .__ __. Sidte Work Done Well Destruction ❑ Wall Diameter _ Sealing Materiul Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Mu septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to s depth of 3 feet: _.._— ____.__._ . _ Water table depth SEPTIC TANK ❑ Type/Mfg _ _ Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation _..._._ Property Line LliACHINO LINK 0 No. & Length of linea .__—_---_ local lungth/size _ FILTER BED CI Distance to nearest: Well Founoabon Property Line SEEPAGE PITS 11 Depth Size Number . SUMPS LI Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accoiddnce 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 riot employ any person in such manner as to become subject to workmen'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 cornpanss tion laws of California." the applicant must call for all required inspections. Complete drawing on reverse side. Signed X L - ✓y� Title: L w��_ _�i�LUC, Date: FOR DEPARTMENT USE ONI Y Application Accepted by C —o ___ Date C� Area f Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental llealth Permit./Service:; 498 N San .Iuuquln, P U box 2000, aL1.11, CA bbLUt FEE INFO AMOUNT DUE AMOUNT REMITTED -C II RECEIVED BY DATE PERMIT NO. EH 1 7-2t INEV.r i n si C r_ Od C I