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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH F S ENVIRONMENTAL HEALTH DIVISI Np� 445 N SAN JOAQUIN, PHONE (209)46 4,D# P O BOX 2009, STOCKTON, CA 951201 c # PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) U 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 [� —,s� /rrl� {"s✓ City Lot Size/Acreage Owner's Name �_�f%Pr' � �— Address �� / s �'�f3rr�f /Q Phone ContractorAddress icense N ' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �. [7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public Cl Other n Delta Depth of Grout Seal MEN I I Irrigation —.Approx. Depth I I Eastern Surface Sedl Installed by !tiC'f'►C'IV60 _ Repair Work Done U Type of Pump H.P. ____ State Work Done_ r Well Destruction ❑ Well Diameter Sealing Material Depth v, 21 Depth Filler Material & Depth ."M InAQUIN COUNTY g TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION 1 1 INo septic e ,*Cu" 's available Installation will serve: Residence— Commercial Other DM.+.. Number of living units: Number of bedrooms y Character of soil to a depth of 3 feet: 4 n 9 e5 Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines �n " l�� Total length/size FILTER BED ❑ Distance to nearest: Well '' Sb r undation Property Line b 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 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 applicant must call lff'or all squired insPecttiikonnss. Complete drawing on reverse side. Signed X „j y,,�Z Title: dna .rte_ Date: L � FOR DEPARTMENT USE ONLY Qom. j Application Accepted by * _ Date �- C Area �' / �- Pit or Grout Inspection by Date Final Inspection by MCt.��t2� Date Additional Comments: sce 141.q= Applicant - Return all copies to: San Joaquin County Public Health Services i , Environmental Health Permit/Services \ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 W FEE AMOUNT DUE AMOUNT REMITTED I ICK-01RECEIVED BY DATE PERMIT'NO. INFO SH . EM 13.21(REV.r i n si EH 11.26