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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 f ,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. 54 and 1662 and the Rules and Regulations of San Joaquin County Public Health/Serrvices. - Job Address �0 7 7 "'� ��/0 City J Lot Size/Acreage X. Owner's Name Address r �r Gh Phone ZO } t Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMI=NT-C1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 Monitoring Well U 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 F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing rDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public to Other -al $ n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal installed by IH. Repair Work Done, 0 Type of Pump H.P. �_ State Work Done _ Well Destruction ❑ Well Diameter Sealing Materiel b Depth Depth Filler Material & Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDlTlON'pQ.DE57RUCTtON I 1 INo septic system permitted if public sewer is i available within 200 feet.F,' Installation will serve: R 'denca Commercial_ Other Number of living units Number of bedrooms Character of soil to a depth of 3 fest: . Water table depth SEPTIC TANK Type/Mfg'. Capacity No. Compartments" PKG. TREATMENT PLT. ❑ _ ,ems Method of Disposal Distance to nearest: Well Foundation a Property Line LEACHING LINE No. 8 Length of lines TyLial Iength/size fin FILTER BED n Distance to nearest: Well �d Foundation , Propeny Line C SEEPAGE PITS l 1 Depth Size --1121- Nupleer oeh SUMPS Distance-tb.nearesl:- Well, •50 Foundation, ropeny Lina" DISPOSAL PONDS ❑ f I 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 for all required ins coons. Complete drawing on reverse side. Signed X �?=1, L ' i� _ Title: wA/e-tc-- Date: OR EPARTMENT USE ONLY Application Accepted by -Date Area Zr *r Gro t n tion by *� ate !� Final Inspection by Date Addit' Carhments: .J 9rc aJ A \Q� �,b1� 34 dYJ Applicant Return all copies to: San Joaquin County`,Public 1"Health Services Endironmental Health Permit/Services `^'} 445 N San Joaquin, P O Box' 2009, Stkn, CA 85201 FEE AMOUNT DUE AMOUNT.REMITTED CK RECEIVED BY f DATE PERMIT'NO. INFO L L/ . EH 13.24 tREV.rrxSJz9f.- I EH 14.2e -