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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) 6� 0 L i0L ff Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. .�...___ )_26% E&V ��7 City Lot Size/Acreage JVV nu - -- -- - �� (?1�y l�yl (/D qll MAdD (ANAL- L� p hone \ 2M/ q,9 -MO Owner's Name Address RECEIVED BY VrC� Def ✓ ' �L -7 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION ❑ Out of Service Well 0 ✓135 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well t1�� DISTANCE TO NEAREST: SEPTIC TANK tPdff SEWER LINES 0 DIMSPO L LD. PROP. LINE ��/ FOUNDATION AGRICULTURE �i LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 41 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation "t' Dia. of Well Casing C.l Domestic/ Private Ll Gravel Pack 1,51i Tracy Type of Casing I&A' PNL1 P/!s Specifications_..lotr,t-, ;PoC."_ I'1 Public (-1 Other 1ENr4> DrA:f (-IDeltaDepth of Grout Seal Ur4f LL Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H. P. __ State Work Done Well Destruction ❑ Well Diameter �� '� Sealing Material & Depth (' r%iG'rI �1�C✓t Depth Filler Material i Depth f k)9JT;-S 1�11n ,iF nr� 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 ❑ 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 ❑ t heroh., certify that I have nrenareA this application and that the work will be done in accordance with San Joaouin county ordinancesstate laws. aniY 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 Califom' The applic nt mu all fror X11 i uired inspections. Complete drawing on reverse side. Signed X Title:ff'LW(44Date S�AFOR DEPARTMENT USE ONLY Application Accepted by --- — Date —. r ' rhea! Pit or Grout Inspection by Additional Comments: Applic EM 13.24 IREV. rin5r EH 14.26 Date _ Final Inspection by Date Return all copies to: San Joaquin County Publid/iiealth Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 Qq fEE AMOUNT DUE INFO AMOUNT REMITTED K C H RECEIVED BY DATE PERMIT'NO. g�I, 0Z)r�j (16) //17 It ✓135 �� t �� ��/