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APPLICATION SR ff 2i SAN JOAQUIN COUNTY PUBLIC HEALT AAD* ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209) 0 ..•� P 0 BOX 2009, STOCKTON, CA 95 PERMIT EXPIRES I YEAR FROM DATA (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 ie ctade in compliance with San Joaquin County Ordinar>ce No. 5119 and 1862 and the Rules and Regulatione of San Joaquin County Public Healt Services, �/� -- — 1 Dti Aub 3 ` Job Address Y �– Size/Acreage __ _ Cn Lot e-- Owner's Name �1�/�S�L�` �(011 Addie a � � � ��hone .✓`1`/`�� "(16,4 1 Address dense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT 7 DESTP,UCTION Fl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER X 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 SPECiFICATigyp Industrial Open Bottom 11 Manteca Dia. of Weil Exc v� `� Dia. of Well Casing 1 f i Domestic/Private C: Gravel Pack (7 Tracy Type of Casing_ _ Specifications C1 Public f_l her iI Delta Depth of Grout Seaf Type of Grout � C' e�11 I r 1400 Approx, De 11 Eastem Surface Seal Installed by T –� p ork one ❑ Type of Pump ii P. to a r ne Well Destruction ❑ Well Diameter Selling Material i. Depth 6 ' Depth _ Y Piller Material i Depth a`ie TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR;ADDITION I DESTRUCTION I I INo septic system permitted if public"sewer is available within 200 leet.f 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 Q Type/Mfg Capacity No. Compartments !� PKG. TREATMENT PLT, CI Method of Disposal Distance to nea t: W _ Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/sizil FILTER BED 1-1 Distance to nearest: W Foundation _�Gn- _1%Prort ine SEEPAGE PITS 11 Dep1h _SiYe er ^_ SUMPS L1 Distance to nearest: Well Foundation Pirwvr jrL DISPOSAL PONDS ❑ '� 2 I hereby certify that I have prepared this. application and that the work will be done in accord a quin county ordinances, state laws, and rules and regulations of the San Joaquin County : �1 '� Home owner or licensed agent's signature certifies the following; "I certify that in the pedorman t�F , work for which this permit is issued, I shall not employ any person in such manna:as to become subject to workman's compensation laws of Cali Contractors hiring or sub-contracting signature certifies the follow q: "I certify that in the performance of the work for which this permit is issued, I Q employ persons subject to workmen's compensa- tion laws of C The appfic ft us[ calf for eI req r inspe ti s. plat drawing on reverse s d . Signed X • / Title: 1 Date: _ 7R DQART USE ONLY I Application Accepted by r f _� Date Area Pit or Grout inspection by Date Final Inspection by r Data Additions; Comrnanw / App Return all copies to: San Joaquin County Public Health Services _. 77AJ V• 9�7'0 b .. Environmental Health Permit/Services (� q p 7� /l 3 r=� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 952 IV-L),-\ 4 (rC IFEE AMOUNT DUE AMOUNT REMITTED �KSH RECEIVED BY T PEftMiT',Np. � ry� EM 1921{REV.1iNsf J_i .�,�' l3(, EH u-2e _ / f I