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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46&-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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / )(Job Address S / N•_ �Q LAW - (�Iq, vG' �A /y� City. Lot Size/Acreage Owner's Name �� ""J r(l. 5/)Ll Address (/ Phone V-Contfactar 1�� Address License Na: Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT F1 DESTRUCTION ❑ Dut of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O 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 O Open Bottom ❑ Manteca Dit. a. of Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ - Specifications_I'] Public Public 1-1 Other n Delta Depth of Grout Seal Type of Grout r I I Irrigation —Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done v Type of Pump H.P. State Work-Done_ Well Destruction . ❑ 'Well Diameter Sealing Material & Depth k Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION INo septic syslam permitted if public sewer is r (� available within 200 feet.) Installation will serve: Residence J Commercial Other Number of living units: d rNT d Character of soil to a depth oPft: Water table depth SEPTIC TANK ❑ Type/Mfg p a Y No. Compartments PKG'TREATMENT PLT.❑ P r j ff��'�d � l� u Method of Disposal A Di fk�bf%;0n ? VOW kJ ndaldd Property Line pe LEACHING LINE ❑ No. Eh~ ;; ; 'IbAt FILTER BED nDistance to nearest: Well Total length/size Foundation Property Line • 1 SEEPAGE PITS 11 Depth j Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDSe ❑ Jr 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 sub-contracting signature certifies the following: "I cenity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws of California." I The applicant must all for a require 'nspec 'ons. Complete drawing on reverse side. Signed ^ 'Title: - ^Date:' FOR DEPARTMENT USE ONLY - Application Accepted by Date`� 1 i Area Pit or Grout Inspection by { Date Final Inspection by Data Additional Comments: I 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 RECEIVED BY TV— INFO CASH GATE' PERMIT'NO. . EH 13"21 IRFV.fiKSI C � T A � 0 1(2 t 13 1 0�1�