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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. T"-+ 4 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 an4 the Rules and Regulations of San Joaquin County Public Health Services. Q�yz Job Address r T &v 0-,0 f-1 P- City Lot Size/Acreage 1 Owner's Name '/ "-`� Address SA/"°jam" Phonee3��7—`7 S Contractor ! Irl/ 6X,I' Address License No 7 `S Phone �? TYPE OF WELL/PUMP: NEW.WELL`S WELL REPLACEMENT El DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATIONS 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 C� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing >W Domestic/Private X*Gravel Pack ❑ Tracy Type of Casing_ ACS Specifications Feil i'1 Public %Other F1 Delta Depth of Grout Seal '7 110 Type of Grout I I tnigation �-9—Approx. Depth1 Eastern Surface ea Installed by r Repair Work Done L3Type of Pump H.P. _—� State Work Done, Q4 L<<yf Well Destruction ❑ Well Diameter Sealing Material & Depth A Depth Filler Material &-Depth `-w- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 lNo septic system permitted it public sewer is available within 200 feet.1 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 ❑ 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: Weil' Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 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 subcontracting 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 mus/�tyalJ�l for all required inspections. Complete drawing on reverse side. Signed X ZX; de •��'.`.,�_ - ,...--- Title: � /� Date: R DEPARTMENT USE ONLY r Application Accepted by Date -A, --Q 2- r Pi o Grout I pection by Final I7pection.by Data t Additional Com nte: ZI a. Applicant - Return al copies t San Joaquin County Public Health Sery ccs d►`1--�" Environmental Health Permit/Services _ y r&-rc � 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 (te'''e"�-► 2 NFO AMOUNT DUE MOUNT REMITTED CASH RECEIVED BY DATE PERma,No. . EH13-24 IRE-.Ii M5) /y')/� kzh� Q EH 14.26 r Jar t! -O i