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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209) 469-3420 P 0 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 Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. V eA+ - r..,,_qof:1(4t) n I., Size/AcreaaeSzo rA i2'7' -1 42 Jame;, hb 2 I J I �1 1 1ri�� Lr� Y Phone "z' 7� Owner's Name Y V 1 .Jc Address : Contractor IIS '` Address 3F'�}I Spy 1 V ' t License No. i ��r'rJPhonki� -7 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well N \/ 5C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION �5 AGRICULTURE WELL OTHER WELL~, P O ' PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation fi'Dia. of Well Casing C C I Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing_aV Specifications I'I Public Cl Other X pelta Depth of Grout Seal Y Type of Grout -PC", +l I I IrnOauon _ Approx. Depth I I Eastern Surface Seat Installed by - Repair Work Done L3 Type of Pump H. P. State Work Do.�e _ Well Destruction O Well Diameter Sealing Material i Depth s Depth _ Filler Material i Depth ',1- /yGYI/%L 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Founaatlon 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 applicanst all f all r uiredji s�pec-tions. Complete drawing on reverse side. Signed X �� " 6/ ``/` '1� Title: % Q� �T' Il�&Date: / C— JL 9' j, FOR DEPARTMENT USE ONLY C Application Accepted by / IIIYYY111��cccrrr>>> t < C% Date kk) Area Pit or Grout Inspection byDate Final Inspection by =� Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health PermiUServices v/ 445 N. San Joaquin, P.O. Box 388, Stockton, CA 95201-0388 • EH 13-24 IREV. I i n 51 EH 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE Y PERMIT NO. (YL 0I 0 Cn co rn d