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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH ERVICES 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 1a hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application Se made in ccmitliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. // CJS '�}r� Job Address z S7/ 6f IiK/� fit/ �" b9 City G[�1v� Lot Size/Acreage `) / Owner's Name /��—//t�' i I` O Address �� 4)� L�� J �Cnt 0 r� Pho C po Bo1F Y 44! 7�� Contractor J l�lr� Address •fin Lc-12. q jry . �j�Z License No.5�2�p� Phone TYPE OF WELL/PUMP: N WELL,0 WELL REPLACEMENT n DESTRUCTION ❑ Out or Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I') Public 1:1 Other Il Delta Depth of Grout Seal Type of Grout I I Imuation —.Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will some: Residence— Commercial_ Other Number of living units: _ Number of bedrooms Character of $oil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well Foundation. Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 1.1 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, 1 shall not employ env person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting signature certifies the following: "I canify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Iowa of California." The applicant In call 1 I required inspgctions. Complete drawing on reverse fi e. z -- � G. Signed K - - Title: © �- C�O ti/ Date: (� Q FOR DEPARTMENT USE ONLY G Application Accepted by '`�'�+�'Y1C� Date JZ .9q Area �✓.D Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . Eh FN Xf� t, yli 24(REV.lin 5) 0 AM