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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Countyy�Publi(cc Health Services. Job Address IleL-u d City Lot Size/Acreage Owner's Name `f Address �Q�� n!]I-v� [� /� Phone 71 W1 Contractor Address V�Q4�C%�/�L _ License Nola Phone_Z ` TYPE OF WELLeUM NEW WELL O WELL REPLACEMENT 171 DESTRUCTION Cl Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR X OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUN lT_IDfV_ __. GRICULTURE WELL OTHER_WEL. IT61.6usd INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f1 F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ryU (1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1 I'I Public 11 Other 1-1 Delta Depth of Grout Seal Type of Grout �f I I Irrigation __ Approx Depth I I Eastern Surface Seal Installed by Repair Work Done (J Type of Pump H.P. State Work Done e ' ?_4 Well Destruction 0 Well Diameter Sealing Material i Depth CZ l .L; -),),Urf�aL 1 4t- Depth Filler Material i Depth [,LI_Q*( .dlQ.90e i�/ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is .Y available within 200 feet.l Installation will serve: Residence _ Commercial Other Number of living units: Nu or of bedrooms Character of soil to a depth of 3 fee . Water table depth �1 SEPTIC TANK ❑ Type/M Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal DistancEf t rfe t: Well Foundation _ Property Line LEACHING LINE Cl No. 8 Len of lines Z Total length/size FILTER BED E_I Distance to nearest: We Foundation Property Line SEEPAGE PITS I I Depth -11 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, ands � 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 persons subject to workman's compensa- tion laws of California." The applicant mustc for all required inspections. Complete drawing on6nerse side. Signed X bJ 11Title: �_ i Date: F DEPARTMENT USE ONLY Application Accepted byDate _ a Pit or Grout Inspection by 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. FM )I74111EV.riMS1pR S, C) f oy -Q-�� fH 14 26