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.• APPLICATION " SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E I L E COPY (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. f �.-, [ City c•,ice/ Lot Size/Acreage _��Mae- Job , Address Address '}±� Y� Phoneme Owner's Name LDDI Contractor1 11 Address License NcL�� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out.of Service Well ❑ PUMP INSTALLATION ❑ 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 C3Open Bottom C1Manteca Dia. of Welt Excavation Dia. of Well Casing [I Domestic/Private [I Gravel Pack ❑ Tracy Type of Casing_ Specifications ['I Public I.1 Other n Delta Depth of Grout Seal Type of Grout t I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. —_ State Work Done _ ~ Weil Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material f% Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION DESTRUCTION I i lNo septic system permitted it public sewer is available within 200 feet.l Installation will serve: Residence>(,,- Commercial— Other Number of living units: 4-- Number of bedrooms Character of soil to a depth of 3 feet: _�►r7�7F�a Water table depth SEPTIC TANK.j�W$y—❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE , No. & Length of lines . 0 Total length/size FILTER BED n Distance to nearest: Well Foundation l2` Property Lina SEEPAGE.PITS 11 Depth 11/ Size �x � / Number SUMPS ( Distance to nearest: Wel `�' 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 subject to workman's compensation taws 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 applican ust ca[I for all required ns ctions. Com to drawing on reverse side. Signed JCTitle: �,r�� z - Date:V AV for 2� � O � � �R DEPARTMENT USE ONLY Q Appli ion Accepts by ��Q��• _ Date {� Area 0 �. Cr •oe or Grout fnape'ction by z7k�!I Ili Date Final Inspection by a• �z j Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �1 _ 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO /� j CASH . EK 13.24(REV.i/M519 `'' � / , EK 14.20 ! / v