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APPLICATION SAN J�iAQUIN COUNTY PUBLIC HEALTH S�VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-34.20 - 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _ Job Address �/� � Ciry�'��N (� Lot Size/Acreage - Owner's Name�,��"'�� C Address /YV.-'1� uCb'[.✓iA' dr ` Phone .3g- Contractor Y/i-Z—h".cJ Z%tt,rnL Address /"10.1Q ,X, �7sLicense Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 11 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 SPECIFICATI,OUS /r f.] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1XI Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications _ CI Public I.1 Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. -- State Work Done _ Well Destruction ❑/Well Diameter ` Sealing Material i Depth SEL t Depth �S+- l05 r Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other - Number of living units: _ Number of bedrooms Character of wil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PIT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founcation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 workmen's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the Wowing: "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 Californis." The applic nt fnu t call for II req d �rcfions. Complete drawing one. rn Signed X Title: 1 //� Date: FOR DEPARTMENT USE ONLY Application Accepted by r Date �S Area ` Pit or Grout Inspection by fir/ - "�� Oat ( y Final Inspection by 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 RECEIVED BY GATE PERMIT NO. INFO " CASH • 00 EM 13 24(REV.I/xs) ' �9 ni Ct $? �7S � 5�a��'3. 93J3`j E 'ba!