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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 slide 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 9e,rYices. Rd,, ,;j.,5-'7o0Cy1rlSw� a-r-� 1do Job Address W.I - 6 A I -C B -1�^fi City Tr„2ccy Lot Size/Acreage Owner's Name ii.S. Army - nngw -Address P n Rr„ ]Phone Isobl+,-tMr,-A Sto 3t3- s oa Contractor--R (DJ Address z/�5 Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)S Monitoring Well by DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIN — (A) FOUNDATION AGRICULTURE WELL y�OTHER WELL PITS/SUMPS Fulp- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Lmg See N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications Attac}Il public ❑ Other FI Delta Depth of Grout Seal Type of Grout WO rk i I Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by Plan Repair Work Done ❑ Type of Pump H.P. __ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments N/A PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 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 ❑ 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: "1 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: "1 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 must cal or all r iced speComplete drawing on reverse side.�]� Signed X Z� Title: ��Aao!�� Date: 2>2. /FG FOR DEPARTMENT USE ONLY Application Accepted by ' ' ` t v� Date S Area LJ TL Pit or Grout Inspection by �� ,(�/ Date Final Inspection by Date Additional Comments: vE/!-V P�-z A LV-�( /' 'ilii, —I Applicant - Return all copies to: an Joa in County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE 99 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. Page IJA . E ;3'24(REV.r/n5) Doc? EHH 1110 C/ �u �+ /