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I, APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH Sj;RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUiN, PHONE (209)468-3420 Fly P 0 BOX 2009, STOCKTON, CA 95201 wl PERMIT EgPIRES 1 YEAR FROM DATE ISSUED itJ, (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. Job Address t City Lot Size/Acreage age 11 Owner's Name rz– Addres ALFP h o n a T 1 I' L�bl Contractora. Phone I AddresssnwLicense Nct�,[ L'?L1–1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ `DESTRUCTION Ll Out.or Service Well ❑ e PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private D Gravel Pack n Tracy Type of Casing_ Specifications Public I I 1-1 Other 1) Delta Depth of Grout Seal Type of Grout Irrigation _Approx. Depth 1 I Eastern Surface Said Installed by Repair Work Done U Type of Pump H.P. Steto Work Done Well Destruction ' ❑ Well Diameter Sealing Material i Depth i Depth Filler Material &.Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRJADDITION DESTRUCTION I 1 (No septic system permitted if public sower is v available within 200 feet.) K; Installation will serve: Residence X-1 Commercial_ Other Number Of living units: il �—J Number of bedrooms 2 •� Character of soil to a depth of 3 feet: 411Water table depth 'i. SEPTIC TANK.�S1•❑ Type/Mfg Capacity No. Compaments PKG. TREATMENT PLT. ❑ I rtMethod of Disposal i Dist nce to nearest; 7 Well Foundation Property Line LEACHING LINE No. 6 Length of lines Total length/size le FILTER BED n Distance to nearest: Well« Foundation �2! Property Line 's,,,_ SEEPAGE.f ITS I I Depth _ Siis Number gd�SUMPS Distance to nearest: Weil Foundation _ Property Line tri_ l DISPOSAL PONDS El (' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats 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 yf 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 comity 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 Caiifornla." The applican ust call for toil uired ns ctions. Com to drawing on reverse side. .i Signed Title: �! I! Date: . f s OR DEPARTMENT USE ONLY Appli Ion Accepted by '�fl � ,�1 Date Area � � •�i t or Grout fns ction by Date Final Inspection by Additional Comments; I s• � Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �c-ti`►� ' N 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 LAG FEE AMOUNT DUE AMOUNT REMITTED iNFO /1 CASH RECEIVED BY DATE PER No. • EH 13.241REV,tAW i� ✓ EH 14-26 e