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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALT UV# ENVIRONMENTAL HEALTH DIVI �} 445 N SAN JOAQUIN, PHONE (209 #2 P O BOX 2009, STOCKTON, CA 9FAt# PERMIT EXPIRES 1 YEAR FROM DA Er L (Complete in Triplicat Application in hereby made to San Joaquin County for a permit to constructand/or install the work beret. descr application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ` Job Address 3_3to C_ x City SCA-4-�•tG Lot Slze/Acreage c p j Owner's Name C-G f Address// Phone Contra 'N l Addre E' G ^ V License SEi Z Phone - y Y_ ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR R OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS LINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Escavanon Dia. of Well Casing LI C omestic/Private Ll Gravel Pack ❑ Tracy Type of Casing_ Specifications I"I Public fl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation /_Approx. Depth I I Eastern i Surface Seal Installed by Repair Work Done 0 Type of Pump H.P./Y State Work Done L Well Destruction CIWell Diameter Sealing Material L Depth W Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public wwer is y - available within 200 feet.) O /� Installation will serve: Residence _ Commercial_ other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: vYat/e�r table depth LSEPTIC TANK ❑ Type/Mfg Capacity lOo961dfi "' PKG. TREATMENT PLT. ❑ a"''��+d Distance to nearest: Well Foundation Pro ne �� p�tj�Qd) �llI LEACHING LINE ❑ No. 8 Length of lines Totalr@'L'/C' gQU) �S FILTER BED CI Distance to nearest: Well Foundation ENV)pptq - L LTH 11yi S 1, f 9.y SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certity 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, I shall not employ any person in such runner as to become subject to workman's compensation laws of California." Contractors 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 applicant mu H,tl"dJ all required�ioss clions. Complete drawing on reverse side. Signed X �.. '.9 JJ o"- Title: _ Date: — G ` FOR DEPARTMENT USE ONLY ,.�!/� /r Application Accepted by s n/�.c- Date h Are /A Pit or Grout Inspection by - Date Final Inspection by 11IIL.. Im a,,Ail Data• 60 Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services L �� Environmental Health Permit/Services P 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AM LINT DUE AMOUNT REMITTED CK RECEIVED BY DAT PERMIT'NO. I O LH13,24IaEV.r/x11 9 "l�