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t APPLICATION a�l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 V Ale VE P 0 BOX 2009, STOCKTON, CA 95201 !{ 1932 PERMIT EgPIRES 1 YEAR FROM DATE ISSUED SPN JolWul1v (Complete in Triplicate) P1��3UG� ��TH S�RVIC1C s I H Q4ViS4QN 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 j"n t5 � &I City Lot Size/Acreage Owner's Name ---- Address Phonede Contractor_ t ICEP1�11.C� Address License No. 26 Phone " yCV TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION K SYSTEM REPAIR ❑, w OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS nIndustrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Weil Casing J6 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public El Other n Delta Depth of Grout Seal Type of Grout I I irrigation —..Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done 06 Type of Pump.Aa&,6_- H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I f DESTRUCTION I i INo septic systempermitted if public sewer is 00 feet.) Installation will serve: Residence— Commercial_ Other available within 2 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. C7 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED C7 Distance to nearest: Well Foundation Property Line 5 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify that f 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 oertifies 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 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 r9puited inspections. Complete drawing on verse side. Signed _ Title: pate: 2 FO DEPAR ENT U ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by _ Date Additions! 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 FSE AMOUNT REMITTED INFO AMOUNT DUE AMO1S!H REGEIVED 8YjEDA;EJF&M�RN,0. + EH 17.21 IREV,I/n 5) EH 14•I0