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APPLICATION �� V 70 SAN JOAQUIN COUNTY PUBLIC HE TIARV �, % 3 ENVIRONMENTAL HEALTH DI 'S 445 N SAN JOAQUIN, PHONE (2 9) 4" t" I P O BOX 2009, STOCKTON, At��ttt PERMIT EXPIRES 1 YEAR FROM ATEaISSUED (Complete in Triplic t• Y 7 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health ,S.e/rrvvices. f V - l��J / L�) y [�� Lot Size/Acres e �C� 'e Job Address '� ffyy-- `-� Cit 8 Owner's Name`_i: C1/ t�-z� Address A'77 t t Phone 333 / 7 z l7 Contractor fw Address t Z icense No. Phone TYPE OF WELL/PUMP7 NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION '❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cil Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications \ I'I Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. -__ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I�REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ✓ Commercial_ ther r Number of living units: _-- Number oJI f erd�ooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK GYType/Mfg �tC'wLL-%Lr - Capacity No. Compartments 2- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Z'0 Foundation `�✓ r Property Line length/size len.� � d LEACHING LINE EL—NO. & Length of lines C Total� g FILTER BED L_ Distance to nearest: Well � Foundation / / Property Line SEEPAGE PITS li-l'—Depth -2 5 r Size Number t< SUMPS LI Distance to nearest: Well f�Cj r Foundation t Property LineL� y DISPOSAL PONDS Cl 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 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 applicaet must call for all re wired in pections. Complete drawing on reverse side. g (r)(,e �r 4 Date: / � Signed X� Title: FOR DEPARTMENT USE ONLY Application Accepted by C Data � V /7—'-SJ R Area �i A� � l �' _t e/d 2� Final Ins �� /��«-� Date/ it or Grout Inspection by Dat Inspection by { 3 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO �I J CASH r • EH 13-24 EH 14.7e(REV/. I L/ CT 1 �., - _ /L S 5, 3 .` O