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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH ''ISERYS S I ENVIRONMENTAL HEALTH DIVISION ! - , - - 445 N SAN JOAQUIN, PHONE (209)468-3 I P O BOX 2009, STOCKTON, CA 9 201 PERMIT E%PIRES 1 YEAR FROM DATE ISST A (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This 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 3q 3S Mb"yam, S7Ck✓&til Lot Size/Acreage (�i�+l S�•2 RA city_.a Owner's Name D 11,J i ZCS � II�Lii"IW Address Ja LKyy 1"S 2i S Phone 931- ,5746 7 `( 1vU i= �sL�NuwT 5.%6',96?!" Contractor - 1.1 Address .4'T7: License No..�yS�,3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION m-� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 Dia. of Well Casing CLB6mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications V I'I Public 1-1 Other ❑ Della Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth 1 I Eastern Sudace Seal Installed by Repair Work Done ❑ Type of Pump ^S Q'b N.P. �2 State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth C[l Depth Filler Material i 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 •'T" n Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal \\1 Distance to nearest: Well Foundation Property Line N LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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, I shall employ parsons subject to workman's compensa tion laws of California." The apphrant must call for all required inspections. Complete drawing on rev side �j �7 C��/I Signal X �� Title: 1 Date: ,, FOR DEPARTMENT USE ONLY go.,, �y1 Application Accepted by �xDate �� 9�(' Area I Pit or Grout Inspection by Data Final Inspection In - Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �LO�J 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE MEE AMOUNT REMITTED RECEIVED BV DATE PERMIT NO. INF'OO CASH EH 13-24 laEV.r/N51 �1 �s• EM 11 a! /I