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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 (Complete in Triplicate) t 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'vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin Ceunty,Pube3�th Services. Job Address Q ` City Lot Size/Acreage / . Owner's Name Address �`�l N � °�r� -1�S•I-- Phone3/,, 7� KContractar 1,44 Mov 1 Address 1 «« � tlrJ1� �{Q 4d_/�License No. 13 SJ Phone - 7-27 TYPE OF WELL/PUMP: NEW WELL• WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Nell ❑ —� PUMP INSTALLATIONI SY57�M REPAIR C7 OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK Q , SEWER LINES Q DISPOSAWFLD. PROP. LINES I FOUNDATION AGRICULTURE WELL OTHER WELL• PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC IFI CAfl& w1 n Industrial ❑ Open Bottom ❑ Manteca Diel of Well Exc -tion Dia. of Well C ing �• �!� XDomestic/Private Gravel Pack 0 Tracy Type of Casing_ r V,6, -__- Specification - os i"l Public 1-1 Other i I Delta Depth of Grout Seal Type f Grout! I I Irrigation 3t .Approx. Depth i I Eastern Surface-Seal Installed by Repair Work`Done 'L7' Type of Pump �, State Work Done-T --� Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW-INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is available within 200 fest.l i Installation will serve: Residence_ Commercial_ Other 1 -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 i s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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-certity that.in,the performance.of the-work for-which this permit is issued,f 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 inspections. Complete drawing on reverse side. 1 Signe V Title: ` , n-e Date: v`Z R DEPARTMENT USE ONLY _ Z i Application Accepted by Date `�^ Area Pit or¢meq t Inspection byDate '�7neI Inspection by Date 21 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services I� Environmental Health Permit/Services �t- 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 jLFEENFO AMOUNT DUE AMOUNT REMITTED CASH K 11 RECEIVED BY DATE PERMIT-NO. . . EH t3-Z4 tREV.t/h 51 jJU cV c.7 t�V ' { � EN 14-Te Q z-�37