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APPLICATION !� —b�U/ skoc)O 7 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION A'O V( `/?5 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 �j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby node to San Joaquin County for a permit to construct and/or install the work bereln described. This application is made in CCmpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.. J/�/� {s-/{/ �Q.y /J�r Job Address 3 6 IP/w L //L/� _ C�isty �C-'1 r sWt Size/Acreage Owner s Name L-�- / lij��Atldress ��/ f�/k..= _ Phone . Contractor0� T �lI"Ad�ress l bGyET/ L 'License No._ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT rl DESTRUCTION ❑ Out Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitori�n,gd-V�e11 C7 DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE C x- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (bi(y ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manleca Die. of Well Excavation,- Dia. of Well Casing I'.) Domestic/Private ❑ Gravel P.67 L7 Tracy Type of Casin e Specifications i'I Public ❑ Other 1l Delta Depth of Grout Seal Type of Grout I ± Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump H.P. $tate Work Done _ Well Destruction ❑ Well Diameter Sealing Material s Depth Depth Filler Material i Depth r„ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDI'i ION I DESTR VCTION I INo sap Gc system permitted it public sewer is \ available within 200 leat.l Installation will serve: Residence— Commercial_ Other _ Number of living units: _ Number of bedrooms Character of sail to a depth of 3 fast: Waren table depth SEPTIC TANK TANK ❑ Type/fki Capacity _ No. Compartments PKG. TREATMENT PLL Ll Method of Disposal Distance to nearest: Well Foundation_ Property Line LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Wall Foundation _ Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS LI Distance to neriresD Well Foundalion Property Line DISPOSAL PONOS ❑ 1 hereby certify that I have prepared thin application and that the work will be done in accordance with San Joaquin county ordinances. stale 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 peplormance of the work for which this permit n Issued, I shall not employ any person in such manner as to bacoms subject to workman's compensation laws of California."Contractor's hiring or sutrconvacting signature certifies the following: "I certify That in the psdormance of the work for which this permit is issued. I shall employ persona subject to workman's compensa- tion laws of California." The applicant must call 10r all required in/a/�peyc)tioro. Complete drawing on reverse side. 'J /Signed % 0 1 Z (�:.•�— / �,`L.C./.J Tithe: Date' C-- !C� 3 �( I FOR DEPARTMENT USE ONLY Application Accepted by Ju _ Darer,- PR or Grout inspection by Data Final Inspection by ,t�D1; Additional Comments: R P.pplicnnt - Return all copies to: San Joaquin County Public Health services Environmental Health Permit/Services 445 N San Joaquin P U Box 2009, StKn, CM1 9 "l,-5 -,OQQ'�7CPr'7 \11 ,FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY a CC// �� pp r fw 1124 ITIEV.11n11 97