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.. APPLICATION SAN ^JOAQUIN COUNTY PUBLIC HEALC �y ENVIRONMENTAL HEALTH DIVI y 445 N SAN JOAQUIN, PHONE (209 P O BOX 2009, STOCKTON, CA FAh PERMIT EXPIRES 1 YEAR FROM DA EID —� [ (Complete in Triplicat ) 1N _ Application in 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 Sery Job Address 4 .\N - w ) 2— City Lot Size/Acreage Owne('s Name _ rG r) nETru WdId s1 V U V ► Phone `' I L MI Contractor j� f ) �"' Address �k License No. Phone C� TYPE RL OF WELL/PUMP: ! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service'Kell 5 PUMP INSTALLATION 0. SYSTEM REPAIR ❑ OTHER D Monitoring well L7 } DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE ,WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFi11 CATIONS - Y''C1 Domestic/ ❑ Gravel Bottom ❑ Manteca r Dia. of Well b,cavaiion. H Cl Industrial ❑ 0 lgia:�of Well'Casing j Pack ❑ Tracy Type of Casing_ Specifications "hPublic :P,ih6c 1:1 Other n Delta Depth of Grout Seal `° Type of Grout I I Irrigation —'Approx. Dn l Eastern urface Seal.lnsialled by Repair Wor *Wu Dottie U Type of Pump l .P. State Work,Done Well Destruction• ❑ Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTAL-L-AT16N - - REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sevver is s _ II available within 200 feel.1 Inataliaiiori`wlll ti`enie: Resident"e-_ Commercial_ A-.gther Number:ofliving toils: .Number of bedrooms i Character of soq to a depth of 3 feet: " ; I Water table depth SEPTIC TANK ❑ T /Mf c YPe 9 ...,_ Capacity l No. Compartments PKG. TREATMENT I L"T'v❑ i I Method of Disposal Distance to nearest: Well i Foundation i Property Line - - LEA RING LINE L1 No'. & Length of lines To at length/size 'FILTER BED ❑ Distance to nearest: Well t Foundation Property Line I s I SEEPAGE PITS It Depth Sue Number SUMPS Ll Distance to nearest: Wolf 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 laws of California." Contractor's hiring or sub-contracting signature ,crrrtifies 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'componsa- :tiomlaws of Colifornla." 'The applicant must call for all required insPection . Complete drawing on reverse side. . .Signed i Date: I� FOR DEPARTMENT USE ONLY ;Applicatlon Accepted by � Date �r Area iPit or Grout Inspection by to Final Inspection by • Date Additional Comments: i ; A w. Applicant - Return all` copies ,to: San Joaquin County Public Health Services j Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201INFE AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED 9Y DATE PERMIT NO. Ens 3-24 cn>v.,,K sl 00 �03 C � I Eli 11.26 -