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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in 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. Q( ) /-7 Vt'�O City C Lot Size/AcregB� �_ Job Address ��! Owner's Name -"_•_� Addrress { yr� I Z 1-77 r /' f ve� 7 �f Contractor Gr - Address ffiOt License No. 6 0 / Ph RPd -40q TYPE OF WELL/P NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTAL ION ❑ SYSTEM RE,rAIR ❑ �O��T-�HHEER�R �it�orrigng/Well Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z19 DISPOSAL FLD._ PROP. LINE JC`Z�`� FOUNDATION 9 4_7 AGRICULTURE WELL i" OTHER WELL PITS/SUMPS c�vv INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- - Specifications y� Cl Public FI Other n Delta Depth of Grout Seal i Type of Grout I I lmgauon —.App(ox, Depth I I Easlern p§urface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well ction ❑ Well Diameter k•JSealing Material & Depth Destr j Depth Filler Material & Depth TYPE OF S PTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of wit to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to dearest: Well Foundation Property Line LEACHING LINE ❑ No. & 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 ❑ 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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa tion laws of California." The applicant mu call for all required inspections. Complete drawing on reverse side. 9 Signed �h"y SIE^1Mavt,S Title: Date: 1;P1�" / FOR DEPARTMENT USE ONLY Application Accepted by �(J "" 7� ( / Date 12� '�L' Area Pit or Grout Inspection by DateT Final Inspection by . 11 Date Additional Comments: _Fj'�Gr o+x.hYh¢.-tet TC.✓N1I �(ESoso ISS b�COS 12.29.9' 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 INFO AMOUNT DUE //AMOUNT REMITTED CASH �A RECEIVED BY DATE PERMITNO. . Ea 1]]I IREV.,ixs) 'TAb 12310. WJ EN IMO t INN v� r