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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) 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. f Job Addressr r "r c� City Lot Size/Acreage n /�aw {�J�/�nOwner's Name 1 I a 1Tc rd at l _Address 4Aq (�' ' _ _./( 1 -CJI,t Phone Contracto Address fi License No. `�M Phone l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA t5ENT Cl DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well X DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE C1 Industrial ❑ Domestic/ Private I') Public I I Irrigation Repair Work Done ' Well Destruction OF SEPTIC WO TYPE OF WELL ❑ Open Bottom ❑ Gravel Pack FI Other _ Approx. Depth Type of Pump Well Diameter Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS AUL ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fi ❑ Tracy Type of Casing_ ��,. Specifications fl Delta Depth of Grout Seal Ty of Grout r I I Eastern Surface Seal Installed by Vr ;sare �rar , tna H. P. State Work Done _ Sealing Materiel i Depth Filler Material i Depth NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available w bin 200 feet.) Installation will serve: Reside Commercial _ Other AM CASH Number of living units: Nu r of bedrooms Character of soil to a depth of 3 feet: &0 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearWellndation Property Line LEACHING LINE ❑ Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation operty Line SEEPAG S I I Depth Size Number SUK S L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 n in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub -contracting signature certlfie a follow g: "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 I s of Califor ia." r� The ap licant mus caJl for all r uir inspa o mplete drawing o r se side. idd Signed X Title: fL �l` jy' Date: Application Accepted by Pit or Grout Inspection by Additional Comments: v Applicant - Return all copies to: • EH 13.24 (REV. i / h s, EH 14.26 FOR DEPARTMENT USE ONLY i, Date L �' U L q �J Area Date `0'� Final Inspection by ��/ I '� � Date L c, f 1 Uc�oL QK`f�'�CftcS� t�� San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA AMOUNT REMITTED CK RECEIVED BY TE PERMIT NO. L l FEE INFO AMOUNT DUE AM CASH T_��D &0 1 32� WAS to: « x{ rra