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f APPLICATION V" �s.. SAN JOAQUIN COUNTY PUT!LIC 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. ['� J[Job Address 73J-7-- New ea s�I� 4\Q r e�f City�� Lot Size/Acreage • owner's Name J9 CZal Address �� t C Phone O 5 fRContrattor _�Lclt1 i� Address Sit �i License No. Phone `TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER &p Monitoring fell E� /�Lefl�S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS L-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications vV` i'1 Public EI Other fl Delta Depth of Grout Seal Type of Grout 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 L Depth Depth Filler Material lir Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is 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 SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines R Total length/size FILTER BED C❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS LI Distance to neatest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby cenify that 1 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 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 applica must aU for all required inspections. Complete drawing on reverse side. /[� Signed Title: _�f Date: : ! v �� FO DEPARTMENT USE ONLY G Applicstion Accepted by QDate Arob �Pit or Grout Inspection by Date .Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ECEIVED BY DATE PERMIT NO. rrr�II1NFO �1l� CA a, + EM13-24IREY.riMai f T '!`�L/ 67o c� d /G €M 11!•76 fff Q