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f ±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 k � v+1 P �'� S� 1 { pERMIT EgPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) herein described. This and/or install the uorlt Application is hereby made to San Joaquin county for a permit to construct 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 D �G.r' City�r J;ot Size/Acreage r � 6Z 4,— Phorie 94 Address Owner's Name License No��,_S�D -Phone I j. Address �` Contractor DESTRUCTION Cl put of Service Ne11 L1 `4 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT Cl Monitoring well ❑ ? PUMP INSTALLATION)% SYSTEM REPAIR ❑ OTHER ❑ i DISPOSAL FLD. PROP. LINE DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES ��--�-- pITSISUMPS FOUNDATION AGRICULTURE WELL OTHER WELL�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS iia- of Well Casing D Open Bottom Manteca Dia. of Well Excavation n Industrial Type of Casing_ Specifications Domestic/Private ❑ Gravel Pack C7 Tracy Depth of Grout Seal w F' Type of Grout 911 1'1 Public Y 11 Other C 1 Delta v ~ x + r urface Sedl Installed by Alirrigation —ApproK. APJb I Eastern State Work Done + Repair Work Done L] Type of Pump Jl �� Sealing Material & Depth I { Wali Destruction ❑ Wall Diameter` Filler Material & Depth Depth TYPE OF,SEPTIC WORK; NEW INSTALLATION 4 I REPAtRlADDITION E 1 DESTRUCTION { I aNailabetlwihin 200 est.c SY510 If p tic sewer is ` Installation will serve: Residence Commercial_ Other -- Number:of living units: Number of bedrooms Water table depth E Character of soil to a depth of 3 feet: Na. Compartments SEPTIC TANK ❑ Type/Mfg ' Capacity j Method of Disposal Il PKG. TREATMENT PLT. 0,; property Line Distance to nearest: Well Foundation s ab f Total length/size LEACHING LINE ❑. No.,& Length of lines Cl Distance . FILTER BED ance to nearest: We Foundation — Property Line ll �+ Number SEEPAGE PITS I I Depth __Size Property Lina ! Well Foundation SUMPS 0 Distance to nearest: _ f 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, an { rules and regulations of the San Joaquin County re -following: "I certify that in the performance of the work fo, which this permit is issued, I shall n t Home owner or licensed agent's signature certifies the employ any person In such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature " n the pe of the work for which this permit is issued, I shall employ persons subject to workman's compensa certifies the following: I certify that ierformanc tion laws of California." The applicant t call f r all required inspec'ons. Complet drawing on to rse side. r Title: Date: Signed 4 I FOR DEPARTMENT USE ONLY `7 4A .- Date y r Application Accepted by Final Inspection by Dat Date e k Pit or Grout Inspection by,;: - i k Additional Comments: Applicant - Return all copies to: San Joaquin county Public Health Services Environmental Health permit/Services kF 445 N San Joaquin, p 0 Box 2009, Stkn, CA 95201 �K RECEIVED BY INFO DATE PERMIT•N0. i? AMOUNT DUE AM NT REMITTED A p AMO.� dal . EH 13.24 IREV.I/ EH 14.26 _. rf