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APPLICATION T SAN J QUIN COMM PUBLIC HEALTH SEBYICTS s ENVIRONMEDITAL HEALTH DIVISION " 445. N SAN JOAQUIN, PHONR (209)468-3420 Y, P O BOX 2009, STOCKTON, CA 95201- . _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby msde to San Joaquin County for a permit to construct and/or install the work herein described. This application In =sde in compliance with San Joaquin County Ordinance No: 549 and 1862 aid the Rules and Regulations of San Joaquin County Public Health Services. ' ' A eC 4 l i J u �,d C;t �e �n Lot Size/Acreage Job Address .37 3 Owner's Name n n t? 5 Pr ) e J Address N Sc o Phone. -5-77— /6 a �ra�lyd rr a� r r �J�S 7 PJr t C. J 1 4.4c;y:7 . �/.✓Z •_ Contractor t,r 1 A1C Address it �� cl �M 4V52. O V License No. j 3 Phone 67/'.2327 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ -- DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ 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 SPECIFI&ATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia..of Well Excavation eN� Dia. of Well Casing Z " n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSC,(,4/J P✓C Specifications Il Public Cl Other f-1 Delta Depth of Grout Seal �^ Type of Groutr0e>-e.4 S1141AW/' I I Irrigation tA AX 4oApprox. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done_ Well Destruction ❑ 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 L- available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of &oil to a depth of 3 feet: Water table depth i SEPTIC TANK. ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 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 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, 1 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 parsons subject to workman's compensa- tion laws of California." The applican must I for all r uired inspections. Complete drawing on reverie side. Signed Title: /i't�f (7 /' 'a�1 oz:�== Date: FOR DEPARTMENT USE ONLY 'f C} �6 Application Accepted by Date °'f2 r L Area Pit or Grout Inspection by Date Final Inspection by Data 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 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVE BV OAT E PERMIT'N0. INFO 9 CASH EH 13-24(REV.1/h 5) EH 14.20 �/(