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APPLICATION • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ;,I_T!1 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 fg 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 -dark herein described. This application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulation, of San Joaquin County Puhiic 9ea.lth,a cee _SS[t7y// 1M� Joh Address j� /j Q ) )T"QQ�\, p2n�/lo � C;gry I`r`k' Loc SS z/e�.'Acreage/' Owner's Name `� S•AR ] — Adore r•Ql-$cF /�DOd�SfGc�CfrYt�. Cfi ('art Phone` �2 — � �' gs1L4G a Contractor 11 ( gs�� 3 dA _ ril.� `^ pi lC ens, No. d(Oa l PDo TYPE OF WELL"'PUMP WELL ❑ WELL REP"LACEMEN DESTRUCTION _. Out of Service Well ❑ See 1/v70�/�, 4n PUMP INSTALLATION C SYSTEM REPAIR _. OTHER = Monitoring) Nell DISTAN E TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �X'''''OL y� FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F'. Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C Gravel Pack 0 Tracy Type of Casing Specifications Il Public f Other I- Delta Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth I I Eastern Surface Seal Installed oy Repair Work Done ._. Type at Pump H.P. State Work Done _ Well Destruction v Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I ; (No septic system permitted if public sewer is N available within 200 lest.) 'Installation will serve: Residence _ Commercial_ other Number of living units: _ Number of bedrooms Character of sod to A depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. i Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS it Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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, I shall not employ any person in such mill as :o become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certity that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa. tion lawn of California.', The applicant smust call for am uired inspections. Complete drawing on reverse side. ( ) Signed X . //��•�`�4 �C Grti_ Title: Fire,/d C c n C Ci r u/ fo r Date: 6 1/ `C FOR PEPARTMENT USE ONLY /� r,, 9 Application Accepted by Date 7 / r "' Area [ Pit or Grout Inspection by Date Final Inspection by Oat Additional Comments: y Applicant - Return a11 copies to: San Joaquin County Public Health Services Environmental Health Permit/Services L 445 S San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO EE AMOUNT DOE AMOUNT REMITTED CACxSH RECEIVED By DATE PERMIT NO. (�tt '$� _`�'>'� '1 �? `1 Page 13A EM 3.21[REV.veal `{ M a