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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209) 469-3420 P O BOX 388, STOCKTON, CA 95201-0388 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 Development Title Section 9-1110.3 and Section99-1115.3 andtheRules and Regulations of San Joaquin County Public Health Services. i�/JL�A � � //:',7Y" Z. Size/Acreage ix P ' %3 ✓�� Owner's Name L[!�"�%C �n Address ` r/U��' hone CASH CK RECEIVED BY DATE PERMIT NO. Contractor /� Address11e ��h %��/ /` � �rJ%1[ri" License No.( Z : Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION G SYSTEM REPAIR '7 OTHER 2Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A DISPOSAL FLO. /f/ PROP. LINE 'r[, FOUNDATION AGRICULTURE WELL fl'" OTHER WELL �. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing ✓� C l Domestic/ Private O Gravel Pack ❑Tracy Type of Casing_ A.Ifl Specifications I'1 Public 1-1 Other 1-1 Delta Depth of Grout Seal ��/ / Type of Grou � '% r -W . I I Irrigation __ Approx. Depth )d Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done _ Well Destruction O Well Diameter Sealing Materiel i Depth Depth _ Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is 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. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 applrcanty3ust c II tor_ II required ins ctions. Complete drawing on reverse side. Signed X ,ZY Title: / iJ /��/}lw�jf� � Date: G �� Application Accepted by Pit or Grout Inspection by Additional Comments: FOR DEPARTMENT USE ONLY Date Date J 7 Final Inspection by A fl - Area Date;ZZO S App l is ant - Return all copieE(to: San Joaquin County Public Health Services � Environmental Health Permit/Services 445 N. San Joaquin, P.O. Box 388, Stockton, CA 952 88 ) EH 1324 (REV. i i n s EH 14.20 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. Ci its 7% 1i), 1i), rn in a