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APPLICATION SAN 'rOAQUIN COUNTY PUBLIC HEALTH oERVICES 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 15 hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application Is made in compliance vith Ban Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / n, Job Address .? eeel V�K /�/ City /r��l'T Lot��Size/Acreage lZ7 /4�.5 Owner's Name �1J yf V oe Ej{/ Address Aja� ol, GL QN&AW40 Phone <17e-1071 Contractor Address Q loy License No.�.>�� Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications FI Public fl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material 4 Depth Depth Filler Material L Depth (/- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.l Installation will serve: Residence A Commercial_ Other Number of living units: --4 Number of b2odlooms_ -3 Character of soil to a depth of 3 feet: l-.[.0-Y Water table depth SEPTIC TANK ❑ Type/Mfg rf1 A112JZZT Capacity--j—&-00.. No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well -50 Foundation Foundation/0 Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _SQ E Foundation Property Line SEEPAGE PITS X Depth _ C9f Site Number -21 SUMPS LI Distance to nearest: Well -190.� Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workmen's compensa- tion laws of California." The applicant must call for NI required inspection . Complete drawing on reverse side. , +, Signed % t.4tL I✓iili� Title: � r ,./-� Date: ay� S""—' Y// {^\ MF DEPARTMENT USE ONLY Application Accepted by b"� � e s.:Cy - Date `w Area V Pit or Grout Inspection by Date Final Inspection by Date 7 VNa. _ ' J kN Additional Comments: Fir Applicant - Re Health Services�/�q Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 20 K �l/utl-( 'x v FEE NFO 1A1MOUNT�DrUaE AMOUNT REMITTED C SN(A RECEIVED BY DATE ^ PERMIT'NO. C`�27 . EM I].]a IREV.r r x 51 1I .Q \/ a fl t/� AJR5 19`51 2- qz- 4/a EH Ir a0