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APPLICATION SAN 'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 x, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k�P �� (Complete in Triplicate) Application is hereby made to San Joaquin County fora permit to construct and/or install the work herein described. This application is made in ocapliance with San Joaquin County Ordinance.No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.. Job Address' �- '/ria _ �4(/� City Lot Size Lre /} ftL e Owner's Name ✓ !M -, ✓ Address � �- w�- ' Ph'o]ne Contractor�� Address a��, ./c�i ��di License N C/) .Phone TYPE OF WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR"?r OTHER C1 Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .POOP.-LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca- Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout [ Xrrigation —Approx, Depth I Eastern Surface Seal installed by V Repair Work Done 16Type of Pump H.P. __ State Work Dona Well Destruction ❑ Well Diameter Sealing !Material & Depth Depth Filler Material & 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 serve: ,.Residence.,. Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total lengthtsize FILTER 9ED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Cl 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 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." The applica s all for all required inspec ions. Complela Brewing on rev a side, i , Signed Title: T� S _.. Date: FOR DEPARTMENT USE ONLY Application Accepted by Date rea Of Pit or Grout Inspection by Date Final Inspection by Dat ell Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services EnvironmentalAiealth Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT NO. a FH 1 *241REV.IiHs! t�j EH i44.20 ttJJ o '0, (may'