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} APPLICATION 4 ' • '� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a { 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) t Application is hereby made.to San toaquin County for a permit to construct and/or install the Work herein described. This application is made in compliance with San Joaquin Cotinty Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �. :='9of7 Address City!ZgW Lot Size/Acreage��X !.� Owner's Name 21A Ai,-Address Phane Contractor /S1MS Addres r License N _Phon TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT . T, DESTRUCTION ❑ Out of service Weil ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR,ED" OTHER ❑ Monitoring Well • t a- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL --- OTHER WELL -• PITS"/.SUMPS 7:% INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom C) Manteca Dia. of Well Excavation Dia. of..Well Casing F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ . Specifications i•1 Public 1-1 Other F1 Delta Ddptri dl.Grout Seal Type of Grout I I Irrigation —Approx.;Depth 1 1 Eastern Surface,Seal Instilled by r ` Repair Work Done U Type of Pump '- H.P. _ ° ;r State Work Done ,•.n -- Well Destruction ❑ Well Diameter Sealing-.Material &•Deph Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR7xe00tT10N- - DESTRUCT) N-1-1�(-No-sep(icsystam-Oerriiitted if public sewer is available within 200 feet.) Installation will serve: Residences Commercial_ Other ° "� gcY t _..4'',�----«. • Number of living units: -I— Number of bedrooms �_ - Character of soil to a depth of 3 feat: r2�? � '<`= Water fable depth SEPTIC TANK Z7467—❑ Type/Mfg H Capacity- No` Compartments PKG. TREATMENT PLT.❑ .. Method.of Disposal Distance fo�nearest: Well Foundation ^P_roperty L'iite _776 LEACHING LINE AM No. & Length of lines Total.length/size rE FILTER BED ❑ Distance to nearest: Well r r ! •. Foundation Property Lina SEEPAGE PITS ��„' :Depth` s Size , Number SUMPS Ut Distance toI+nearest: Well Foundation �.� Property Line DISPOSAL PONDS_,._. __❑ �F i I hereby certify that I have�pre)iared this application and that the iaofk will be done in accordance with'San Joaquin coOnty ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 subcontracting signature certifies the following: "I certify that in the performance of tha work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call tor all requtrad inspections. ompiete drawing on reverie-side --^ Signed , Title. i F DEPARTMENT USE ONLY rDate � � Area •�� Application Accepted by Pit or Grout inspection by Date Final Inspection by J ' Date t Additional Comments: • � '" t Applicant - Return all copies. to: San Joaquin County Public Health Services Environmental Health Permit/Services d 445 N San Joaquin,, P 0 Box 2009, Stkn, GA 95202 FEE INFO YAMOUNT DUE . y AMOUNT REMITTED C ECEIVEp'(3y -^OATE} PERMIT ' EK 13-21(REV.s/x Sl JA J „q c� / �f