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h APPLICATION SAN JOAQUIN COUNTY PUBLIC 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 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. J y� Job Address Xql City�_/1 C! Lot Size/Acreage ' Owner's Name Address 1��3 r, FSMOA��^/J�a4.i Phone Contractor Address Q� Y Az-AM TYPE OF WELL/ U p NEW WELL ❑ WELL REPLACEMENT 5 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 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 SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing k ltkDomestic/Private 0 Gravel Pack El Tracy Type of Casing_ Specifications h I'1 Public I.1 Other n Delta Depth of Grout Seal Type of Grout i l I I Irrigation _ Approx. Depth I I EasternrfaeeASe�al Installed by Repair Work Done �{ Type of Pump _ H.P. �� 1A.¢ State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth 4Q Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTI N f I (No septic system permitted if public sewer is [ available within 200 feet.) l�� installation will serve:' Residence— Commercial T 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. 0 Method of Disposal Distance to nearest: Well Foundation Property LinePAY ENT A KEGEIVEIVI LEACHING LINE L-1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line )I . SAN SEEPAGE PITS 11 Depth Size Number SUMPS El.—Distance to nearest: Well Foundation Prop JW{N� , ._... DISPOSAL PONDS ❑ " 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 I 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 worst 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on rev se side. C �fff1 � Signed X Title: d' rrr.,Q-C.l� Date: DE T LY Application Accepted by Date a Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services IEnvironmental Health Permit/Services E445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEEF INFO AMOUNT DUE AMOUNTR�E/yMITTED CK 11 ASH��7/ RECF ly4ED,BY DATE PERMIT'NO. . EH 13-24IREV. J EH 11.2E dd