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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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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 '� CitAk t Lot Size/Acreage Owner'a Name Address z Z w• EG(IU�' ____ Phone �d Contractor✓_!d5,lLd u"' AddressP 0,60Y W91 5-1-p- (�A— License No. Q Z Phone ' TYPE Of WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well [3 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 LI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ fa Domestic/Private Cl Gavel Pack ❑ Tracy Type of Casing_ Specifications I'I Public Cl Other f-1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I lrastern Surface Seal Installed by Repair Work Done 0 Type of Pump _ H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material 8 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1.4" REPAIR/ADDITION,I 1 DESTRUCTION No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence Commercial— Other r Number of living units: Number of bedrooms I Character of soil to a 14pth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 'Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth, Size Number SUMPS LI Distance to nearest: Weil 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 peifotmance 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 st I for all r ' d inspections. Complete drawing onn_javer a side. 7 �j Signed Title: "" Date: 5 1QFNIIEPARTIVIENT USE ONLY A �r�__ `�A.. �.�....e.,w pplication Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK R CEIVED BY PATE PERMIT'No. INFO // . EM t3-2�trtlyt�-?a .Db 6 (f Lo I i(P 15�% r EH