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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) 0o,1/7�y 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. LJI)r.,„ S LPeCK tdK Lot Size/Acreaue y 4 C &• E 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X M% �✓� rt, t( t'i'�z� % Title: i? F J- tom- ey <c 415 Date: e FQRIOEPARTkIENT USE ONLY Application Accepted by Pit or Grout Inspection by Additional Comments: _ Date / Area Final Inspection by Date Applicant - Return all copies to: San Joaquin County Public Health Services 3 r O Environmental Health Permit/Services S 445 N San Joaquin, P O Box 2009, Stkn, CA D.It 13.24 (RE'.+. I/ M 5 ) EH 1446 FEE INFO 3 Cy f hre e 4. �gC 6140 °� 'fn Phone Wk_ 141-72 ( �rP f1� Q (' y' `-r Owner's Name ,1 , rs Address Contractor Address jizt 1--.0 License No. C i 7 fS21��Phone qJ6 -173 -111S! TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well i DISTANCE TO NEAREST: SEPTIC TANK BMW SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION � AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATICINS / H F.] Industrial O Open Bottom O Manteca Dia. of Well Excavation i Q C N Dia. of Well Casing_ �l Domestic/ Private O Gravel Pack O Tracy Type of Casing_ -_FISC_ Specifications Lx (Pt lic 1-1 Other 1-1DeltaDepth of Grout Seal 2- 0 Type of Grout 000-7 4-4*aIN P rl r Uation __ Approx. Depth I I Eastern Surface Seal Installed by O/« TA%K Repair Work Done O Type of Pump N.P. __ State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK. NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTION I I (No 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 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 CI No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X M% �✓� rt, t( t'i'�z� % Title: i? F J- tom- ey <c 415 Date: e FQRIOEPARTkIENT USE ONLY Application Accepted by Pit or Grout Inspection by Additional Comments: _ Date / Area Final Inspection by Date Applicant - Return all copies to: San Joaquin County Public Health Services 3 r O Environmental Health Permit/Services S 445 N San Joaquin, P O Box 2009, Stkn, CA D.It 13.24 (RE'.+. I/ M 5 ) EH 1446 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY C DATE PERMIT' NO. ule Q