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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES S ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) (�1,`]{y'� , Application is hereby made to San Joaquin County for a permit to construct and/or install the work 8erein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Viob Address I,), City Lot Size/Acreage X'� �U Owner's Name rill' � 7� Address _S df 571- C:. Phone Contractor Address /led d � License No.!?—IT (03 Phone YPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEI`i REPAIR ❑ OTHER D Monitoring Well [3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications I'I Public El Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I 1 Eastern Surface Sedi Installed by Repair Work Dane 13 Type of Pump ` H.P. State Work Done_ Well Destruction ❑ Well Diametef Sealing Material & Depth O Depth Filler Materiel & Depth t� TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1 I DESTRUCTION (Noseptic system permitted if public sewer is V 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 in SEPTIC TANK © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 fallowing: "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 workmen'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." heapplicant must call for all t ui d inppecti s. Complete drawing on reverse side.. Signed X - -..i4 Title: _ s! r►•�4"/ls' — Date: F R DEPARTMENT USE ONLY Application Accepted by - Cy n Date Z` f Z' Area d Pit or Grout Inspection b ate Final Inspection by Date Additional Comments: 7 / Applicant - Return all copies to: an Joaquin County Public Health Services low, Iinvironmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 9 201 # FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT N INFO l ^� /CASH[ Q�y • EH 5,.2�I IREV,iinSl 7�v� �� OV LST l` �.f00