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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEAL ENVIRONMENTAL HEALTH DIV 445 N SAN JOAQUIN, PHONE (201 P O BOX 2009, STOCKTON, C) T (Complete in Triplica C>t)i;14fzL 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. l_A. 1!4 1-/' /I /lir'!) / IJ LP. r,.,,:Sfi,rk r/iil t.m. S17.P/ArrPaaP NA Owner's Name 1 C�/1 Cf C iiS r-�YC✓ �iD �� J[ 1'� IUCC�_� /Ji'1 ye- Phone 1 `36 - C 3A) Address O` J Com CASH tsLf fl kfi Cfe K C 46N(, rcjtt,^ �" _ i , 4� 1�� '4 "Ag Contractor c Address License No. PhoneLjC,� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ci DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �K Monitoring Well O N&3) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. INE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS FI Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing C Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications I'1 Public (1 Other P Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 13 Type of Pump H. P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ^(CA/C — available within 200 feet.) Installation will serve: Residence _ Commercial _ Other _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Founoation Property Line SEEPAGE PITS 11 Depth Size _ _ Number SUMPS LI Distance to nearest: Well Foundation Property Line i 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." G1.). iL). j-rb:%:,ti,) / Sof- The applicant must call for all required inspections. Complete drawing on reverse side. Plewe I'e-k✓ IL pleap rc✓�'��P` a/` " Signed X A-�i t111(_C_— � LLL .f Title: �M+/i 1).1 rl'd f )a i's Date: 3-1,6-24- Application Accepted by Pit or Grout Inspection by Additional Comments: Applicant - Return all copies to EH 13-21 (REV. iiH5) EH 14 2e FOR DEPARTMENT USE ONLY Date !1 ? - Date �3 Area : f Final Inspection by Date Z J San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95 1 n �� CK RECEIVED BY DATE FEE INFO AMOUNT DUE AM OUNT REMITTED CASH GylGv ;'�%--✓ .� � '�� �/�� .�/�:,�% 7 x'35'