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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 &L, I P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) pplication 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. Job Address �7 +� /1 �= ' Ciry � T�)Lot Size/Acreage IVt _ r Owner's Name Address D S. ! a XL/ Phone a - S Contractor S, Address License No, k Phone TYPE OF WELL/PU NEW WELL Cl WELL REPLACEMENT n DESTRUCTION Out of service We11 ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ Monitoring well L7 { 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I C-1 Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. ofiWell Casing "--" "FCa�Domestic!Private ❑ Gravel Pack ❑-Tracy Type of Casing_ Specifications I'l Public L-1 Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation - —Approx. Depth l I Eastern Surface Seat Installed by I Repair Work Done- 0 Type of Pump., H.P. _-- State Work,Done_ Well Destruction ❑ Well Diameter sealing Material i Depth [ „ Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION E I DESTRUCTION l I INo septic system permitted if public rawer is I available within 200 feet.I 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—,. II �f SEPTIC TANK. 4 ❑ Type/Mfg Capacity No. Compariments r 1 PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest. Well ^Foundation t Property Line LEACHING LINE ❑ No. & Length of lines I Total length/size FILTER BED 0 Distance to nearest: Well Foundation I Property Line s SEEPAGE PITS 11 Depth } Size Number SUMPS Ll Distance to nearest: Well Foundation t 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 t Home owner or licensed agent's signature certifies thaIfollowing: "I certify that in the performance of the work for which this permit is issued, I shall not QT 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 stall employ persons subject to workman's compensa- tion laws of California." The applicant st call for 11 r ed inspecti Complete drawing on reverse side. , igned .Titla:- � Date: �� FO EPARTMENT USE ONLY �, r Application Accepted by �"` Date lam Area Pit or Grout Inspection by Date Final Inspection by Data 47LZ4103 l Additional Comments: Z 43 "" !`ns ,�, /� b � =, � -024'l /'/0I' /fr4W Applicant - Return all copies to: San Joaquin County Public Hea&;:s. ices Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 46- FEE FEE AMOUNT DUE AMOUNT.REMITTED 1 CA RECEIVED BY DATE PERMIT'N . INFO f 6' f EH 17.24IREV.fin5 &0, EH 146