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APPLICATION Ip # SAN JY AQUIN COUNTY PUBLIC HEALTH S �� Q� 1 ENVIRONMENTAL HEALTH DIVISITT 445 N SAN JOAQUIN, PHONE (209)46 P 0 BOX 2009, STOCKTON, CA 95 EM PERK T EXPIRES 1 YEAR FROM DATE EIIU (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance With San Joaquin County Ordinance No. 549 and 1062 and the Rules and Regulations of San Joaquin County Public Health Services- JobAddress y -7-0 F' ►' ��SG Ftp yCityv � jdD t Size/Acreage ✓Owner's Name Di Q ' ddress "(X -6" yvnG"(^]�f.� pone �J r Con tractor res �y IW ^ ' Licise No. hone TYPE OF WELL/PUMP: NEW WELLO / WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service Well LlPUMP INSTALLATION f� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'I Public I:1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _—Approx. Depth Ll Eastern I dace Seal Installed by Repair Work Done L3Typa of Pump yy�`ntm H.P. State Work Do _ Well Destruction ❑ Well Dia ter S.L Sealing Material 4 Depth r (,V Filler Materiel i Depth Depth 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 11"t.)V Installation will Residence serve: Reence— Commercial_ Other - 1�` Number of laving units: _ Number of bedrooms L _ Character of wN to a depth of 3 fast: Water table depth SEPTIC TANK ❑ T;0s/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑. Method of Disposal Dwe Distance to nearest Well Foundation Property Line �AY101EP9T .l LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED 4 ❑ Distance to rroarsat:\ Well Foundation Property Lina 2 9 1pJ9A SEEPAGE PITS 11 Depth Sue Number SAND JUOLARUIN COJU'T T SUMPS LI Distance to nearest: Well Foundation PropertyppLIC �I H brm VICES DISPOSAL PONDS ❑ ENVIVNAIENTAtIJEALTH DIVISION 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."Contractors hiring or subcontracting signature conifies the following: "I cenity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lava of Celitornls." The applicant m at ca0 for aN t u ed iiyns�plicc'tii no. Complete drawing on verse side. Signed�.�V per\ Title: Oete: FOR DEPARTMENT USE ONLY c O - Application AccaptSd by �-Er Date ` ` ' Are -7 _ Pit or Grout Inspection Dy 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 14 t O FEE AMOUNT DUE AMOUNT REMITTED 1Z CSN RECEIVED 9y DATE PERMIT NO. . N Et}ix IeEV.„�Sp 4.- S v 1 l3 • z� ` J EN r.-m