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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) 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. 5L9 and 1862 and the Rules and Regulations of San Joaquin County /�Public Health Services. Job Address 15- 7� GrIA��/ • w City Lot Size/Acreage e5 'fe— Owner's Name i /� r �/�/�Address &&'y rI R"yo/`-,yJ � Phone z�i Contractor yI �i �r3j�l`y '�Nddress3 W'AKIK& 4A �14 License No. C'©.� �� Phone TYPE OF WELL/PUMP- DISTANCE TO NEAREST: INTENDED USE n Industrial 'k�Domestic/Private I'1 Public I I Irrigation Repair Work Done U Well Destruction ❑ a NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ Monitoring Well SEPTIC TANK N/A SEWER LINES "%S� DISPOSAL FLD. ti PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL '— PITS/SUMPS � TYPE OF WELL ❑ Open Bottom ❑ Gravel Pack (1 Other __ Approx, Depth Type of Pump Well Diameter _ Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Manteca Dia. of Well Excavation _ Dia. of Well Casing Ll Tracy Type of Casing__rv�' Specifications n Delta Depth of Grout Seal x70 _ Type of GroutAWL41"'D Eastern Surface Seal Installed by /l,1JSff/yiy l�Es1l� �rJ(lls� H. P. _ State Work one _ Sealing Material & DepthiV/%F Filler Material & Depth ¢3 11y� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg PKG. TREATMENT PLT. ❑ Gtt er Capacity Distance to nearest: Well Foundation Water table depth _ No. Compartments Method of Disposal Property Line LEACHING LINE L1 No. & Length of lines _ Total length/size_ FILTER BED [--) Distance to nearest: Well Founaatlon Property Line SEEPAGE PITS I I Depth Size ___ Number _ SUMPS LI Distance to nearest: Well _ Foundation _ Property Line DISPOSAL PONDS ❑ I 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 applicantst 11 or a I required spections. Complete drawing on reverse side. Signed X � ,, Title: ��'� Date: FOR DEPARTMENT USE ONLY Application Accepted by� _ Date Area J Pit or Grout Inspection by Date Final Inspection by Date / Additional Comments: 11feu f Applicant - Return all copies to: SaIV Joaquin Counry Public Health Services Environmental Health Permit/Services s 445 N San Joaquin, P O Box 2009, Stkn, CA EH 1321 (REV. iin5 EH 14-20 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE MIT NO. a x/11