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n APPLICATION SR # ea i ffz- SAN JOAQUIN COUNTY PUBLIC HEALTH S ENVIRONMENTAL HEALTH DIVISIO H) 5Z)0.2.___ 445 N SAN JOAQUIN, PHONE (209)46 -a4� P O BOX 2009, STOCKTON,- CA 95 PERMIT EXPIRES 1—YEAR FROM DATE I SAW# S�((1 y I (Complete in Triplicate) f � , Application is hereby tsade.to San JoaqulD�County for a permit to construct and/oC12 ,- he work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and d fliCl girles and Regulations of San. Joaquin County Public Health Services. - 16 �. l n s Job Address � City I Lot Size/Acr e e f. J Owner's Name Address Phone J_J 6 S Contractor i r u i: Address 4 r Oita � �f'2� g5 License No. SZrr b Phone [ 6 I t TYPE OF WELL/PUMP: NEW WELL © -WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION'0, SYSTEM REPAIR L1 OTHER O Monitoring Well L7 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 Lt"Industrial ; ❑ Open Bottom' C1 Manteca Dia. of Well Excavation Dia. of Well Casing ADomestic/Private ❑ Gravel Packt L7 Tracy Type of Casing_ Specifications I1 Public la Other r h1 Delta Depth of Grout Seat Type of Grout I I Irrigation1 _.-Approx. Oe th I I Eastern S rhea Seal Installed by Repair Work Done L7 Type of Pump ! ""` H.P. State Work Done G?I-t r Well Destruction ❑ Well Diameter _ Sealing Material i Depth Depth 9,0,0 i _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 11 1 REPAIR/AODtTION i I DESTRUCTION i I (No septic system permitted A public sewer is t available within 200 feet.) C lnstallatian will serve: Residence Commercial_ Other Number of living units: Number of bedrooms PAYMENT I Character of soil to a depth of 3 feet: " SEPTIC TANK. ❑ Type/Mfg Capacity i� N*o�n. ooRa �} .PKG. TREATMENT PLT. C1f�lBtlr�d bf �el Distance to narest: Well Foundation ProWN Di LRI Ir HEALTH SERVICES LEACHING LINE Cl No. & Length{ot lines Total 5NV1RGtJ ENTAL 3 FILTER BED C3 Distance to nearest: Welt Foundation Property Line 1 SEEPAGE PITS It Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 Sen Joaquin County � Home owner or licensed agent's signature cenifies.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 sub-contracting signature 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." I " The applicant t cap for all r red iripelctions. Complete drawing on reverse ids. �) 4 Signed X Title: Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date. RVQ Area I " Pit or Grout Inspection by Date Final inspection by Date Additional Comments.- Applicant omments:Applicant - Return all copies to: San Joaquin County Public Health Services T yi Environmental Hsalth't?ermit/8ervices �V 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 - INF FEE AMOUNT DUE AMbUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. • EH 17.2{IREV.I/"'SO 1�+ c- �-7 t �. ✓]y, 1_5 610 / I