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'I1 APPLICATION 1 a.� *.or SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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) 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. ,� Q�J, ,;� ,(,�(ys�,,, Job Address / 3 •J' "�'-`+ A1111 _C,tty/� --t Size/Acreage AdoresPhoner �"'r Phone Owner's Nar75 pp Vif d. Contractor f ddress License No. Phone TYPE OF LL/PUMP: NEW LL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 L7 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public CI Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ,REPAIR/ T S JCTI NII (No septic system permitted if public sewer is �yy1A1 aveable within 200 feet.) Installation will serve: Residence— Comm, Other Q� p Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: ater tabb depthI/TFrE y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments V PKG. TREATMENT PLT. ❑ 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 Lina SEEPAGE PITS II Depth Size Number SUMPS LI 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 ws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall 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 California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FO D ARTMENT USE ONLY s Application Accepted by Date Ana r Ph or Grout Inspection by �J Date B� Faunal Inspection by Date Date Additional Comitants: Applicant - Return all copies to: San Joaquin County Public Ifealth Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMO NT REMITTED k ECEIVED BY D TE PERM17'NO. • EH I4.E5 IREV.vmm NFO EH Wie fil