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APPLICATION r ► 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 vork 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 9 City P' of Size/Acreage Owner's Name ig C Address/V.h� :„j i, _ Phone Contractor 4c,17,di Address cense No, Phone J yr TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK __lQ z SEWER LINES DISPOSAL FLD.-ZO./t PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin )( Domestic/Private 0 Gravel Pack n Tracy Type of Casing_ -- pyd` Specifications C) Public 11 Other 1"1 Delta Depth of Grout Seal Type of Grout��i`DLif 1 I i Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work'Done — Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence— Commercial_.__ Other available within 200 feel,1 Number of living units: ' Number of bedrooms F Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK © Type/Mfg Capacity No. Compartments ti 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 Line �1J SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 Joaq'din 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 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-US/ pplicantmus call for all required i pections. Complete drawing o reverse side. Signed Title: Date: FOR DEPART ENT U ONLY Applicati n Accepted bAby Date "Z 7Z 2112- Area Pit or r t Inspection atJ 7'Fin Inspection by "`��5ate �� T`'2/ Additional Commentsf I 4e Applicant - Return all copies to: San Joaquin County Public Health Services l tj�1 i`f '✓ �� Environmental Health Permit/Services f- 445•N San Joaquin, P O ]lox 2009, Stkn, CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY .M INF ��rr �r7 CASH DATE PERMIT N0. ( } . tH 13-24{REV.F i e S!� � y � `.� � � \e V_ EH 14.26 v 6 • �r _ y �_ � A�1