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APPLICATION "® SAN JOAQUIN COUNTY PUBLIC HE T,Q ER ENVIRONMENTAL HEALTH DI 445 N SAN JOAQUIN, PHONE (268-3 /J P O BOX 2009, STOCKTON, / l PERMIT EXPIRES 1 YEAR FROM D1W ICSUED C1 (Complete in Tripli f Application is hereby made to San Joaquin County for a permit to construct and/or install the work here is application is made in compliance with San Joaquin County Ordinance No. 5L9 and 1862 and the Rules and Regulations o an Joaquin County Public Health Services Job Address J C `' )2:�Jr T'sCity /�C' C>�t Size/Acreage �' L I Owner's Name t c �1/ Address ��_X k�U Phone r Q ` Contractorl - bnrd AA_1 /�Address _3 TIS License No. Phone tJ ac TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK flIJ-Q., SEWER LINES POA/{l 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 UJ [_omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'I Public [_1 Other rl Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by W Repair Work Done U Type of Pump H.P. ____ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth 1 n De t Filler Material i Depth l/ TYPE OF SEPTIC WORK: NEW INSTALLATIO f I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re 'deuce Commercial_ Other Number of living units: T Number of b drooms•__ 1a Character of soil to a depth of 3 feet: /)" r / O r, PA Water table depth SEPTIC TANK A Type/Mfg P 4, Capacity- No. Compartments Z PKG. TREATMENT PLT. ❑ / Method of Dispgsal Distance to nearest: Well Foundation Property Line/ 010p- MIL04V I ) LEACHING LINE CI No. & Length of lines -3— gta1 length/size / ` FILTER BED ❑ Distance to nearest: Well4zniA, Foundation _,-C Property Line C0/ SEEPAGE PITS 11 Depth Size Number SUMPS LI 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, I shall not employ any person in such manner as to become s bject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: ' certi y that in the rfor nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California " The applica usl II fo ns c nsf Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY A-},) S_ Application Accepted by F _ Date d Pit or Grout Inspection by Date Final Inspection by AP44" Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 4 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH1J-N(REV,rind 'j ( l �� L1V 11q. o /2- D 394 ��. /f F (�(.l/3 3 EH 14.20 _ _