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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) 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. ` //y/ Job Address ] t L.� /r� dor- ��6,e 61C'� City�7�Ck Lot Size/!Acreage /`�CJ � 3 Owner's Name 1=2 f`ry /�`N�Q� Address 47 W d UaAr�;i �re one Contractor G � Address -7 /"r gelolr� l'� License No. 1geli 76 Phone E. �77 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (nl Cl Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing_ Specifications f"I Public Cl Other I-1 Delta Depth of Grout Seal Type of Grout 1 1 Irrigation — Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATIONXI REPAIR/ADDITION I 1 DESTRUCTION I k lNo septic system permitted if public sewer is / available within 200 feet.1 Installation will serve: Residence..7!!� Commercial— Other O Number of living units: —k- Number of bedrooms. Character of soil to a depth of 3 feet: A CWater table depth T ` SEPTIC TANK Type/Mfg G Cf apacityl� No. Compartments /;Z _ PKG. TREATMENT PLT, ❑ r Method of Dip osal f� Distance to nearest: Well /f Foundation Property Line I> t+1 i✓L l G LEACHING LINE No. & Length of lines --t� /`� ' 9 , ism.!1. — Total length/size �.� FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth C7 Size !V12_ �X Z�r 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 wilt 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 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 mur call for all required inspections. Co to drawing on reverseAide, Signed Title: iC- 64 _ Date: -k/�' � TMENT USE ONLY Application Accepted by _ �"�!r'ks ��, Date "%fift Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: a d, p//.3/1 yA?3 Applicant - Return alp copies to: San Joaquin County Public Health Services Ara 0'Ir itr Environmental Health Permit/Services 445 N San Joaquin, P O Bax 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'N0. be I ♦ EH 14-26MCV.I/n 51 Q o 1 1 y•