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SAN JOAQ APPLICATION IIIN COUNTY PUBLIC HEALTAERVICES 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 1s 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 Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r 7� �� /� d Job Address City �cscsas..�-vim- Lot Size/Acreage A. 40 /7��1 Owner's Name b, 100L f)'Joel C Address R 3 [. �' sPhone 'S St0 Contractor oy . Address no 9 L G r,Hina L G rt( License No. Alf.0.23 9 O Phone 1�412 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT F DESTRUCTION O Out of Service Well O PUMP INSTALLATION — SYSTEM REPAIR O OTHER O Monitoring Well v{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL r'LD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER W LL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI IC I NS 0 Industrial O Open Bottom a Manteca Dia. of Well Excavatio Dia. of Well Casing R Domestic/Private X Gravel Pack Tracy Type of Casing_ P Specifications I"I Public 1-1 Other Delta Depth of Grout Seal 4oa#2_4 A J Type of G ut I I Irrigation aW Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ State Work Done _ Well Destruction O Well Diameter Sealing Material Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION i REPAIR/ADDITION ( I DESTRUCTION 1 1 INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bearooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number \ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O %; I hereby certify that I have prepared this applicanon 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 n employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature (4I certifies the following: "I 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 call for al rtid in tions. Complete drawing on reverse side. J Signed X Title: �Of4� Date:,,gJ 1 9 FOR DEPARTMENT USE ONLYA-3 _ Application Accepted by Date Pit or Grout Inspection by Date D Final Inspection b Oats Additional Comments: l Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services San Jo 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DA JE PERMI NO. INFO CASH 9 • EH 14.26 EH 13.24(REV.rin5) f/