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c' 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 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. Job Address 1Y2o-!V'7_k City Lot Size/Acreage Owner's Name — Address "'t Phone Contractor C_ Address r 0. G'l icense N,c�'/ 70 S d Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION CI Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR, OTHER'❑ Monitoring Well D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ..PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSNQ r" I n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation_ Dia.•of Well Casing XDomestic/Private ❑ Gravel Pack L1 Tracy Type of Casing_ Specifications O l'I Public 1-3 Other n Delta Depth ofGroutSeal Type of Grout I i Irrigation =fiApprox. Depth l I Eastern Surface Seat Installed by, 42 4 Repair Work Done )0 Type of Pump H.p. � State Work Done V Well Destruction ❑ Well Diameter Sealing Material & Dep_th, Depth. Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION t I REPAIR/ADOITION 4_1 DESTRUCTION I i !No septic system permitted if public sewer is - available within 200 feet.) Installation will serve: Residence____ Commercial_ Other Number of living units: Number of bedrooms V Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i hereby certify that I have prepared this application and that the work wilt 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 taws 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 II for all required ins coons. Complete drawing on rev side. Signed X rte: ^__z__ r ,� Date: k =ORARTMENT USF OfMLY qApplication Accepted by — �O r.wA Date + Area Pit or Grout Inspection by Date Final Inspection by Date 0 d, Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT'NO. INFO •�/y • EN 13-241REV,1/R51 P P_ f �e__ F EW 14.25