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APPLICATION ��pp .µµ _ ----�"" SAN JOAQUIN COUNTY PUBLIC HEALTH S V# ENVIRONMENTAL HEALTH DIVISION �® # R 445 N SAN JOAQUIN, PHONE (209)468 A P O BOX 2009, STOCKTON, CA 952 1FAC # - PERMIT EBPIRES 1 YEAR FROM DATE I UED yj �� (Complete in Triplicate) tt Application is hereby mnde 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. p Job Address D I �p� € (.[j� dj>''/o n f] 13 �I 0 b YQ �iTy_-,1A 61)4/__ ,� Lot Sise/Acreage Owner's Name 0;,7 1-' il 1/Lf !_!'��1,��Address R 90 X � ! 37 11a l Phone.7� p r a Contractor g Address S 16 N �r7Xsw �L icense No. Phone TYPE OF WELL/P P: 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"I Public 1-1 Other 1l Delta Depth of Grout Seal Type of Grout 41If6gation —Approx. Depth I I Eastern Surface Seal Installed by \ \ Repair Work Done ❑ Type of Pump M.P. __ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth •�t Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of sail to• depth of 3 feet: Wapu depth SEPTIC TANK. ❑ Type/Mfg Capacity N AfAl d PKG. TREATMENT PLT. ❑ e � � Distance to nearest: Well Foundation Pro e 0 svl� )�' d LEACHING LINE Cl No. 6 Length of lines To pp�,1�� FILTER BED ❑ Distance to nearest: Well Foundation Pro MTrjy�� H SEEPAGE PITS 11 Depth Sise Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ _ 1 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 applicant must call for all required inspections. Complete drawing on reverse side. P '` q/ Signed Title: ' J -07 7-7 it Date: FOR DEPARTMENT=SEE Y Application Accepted by \v • �� DateS/AT A�rsea z� Pit or Grout Inspection by Date Final Inspection by �� "�-�tGF-tel Date� r Additional Comments: �j J Appl lcarLl - Return all copies to: San JoaqulJC'g-ty}7 Pub117ealthCSe v1�e�� '� - \ `\r Environmental tel Health Permit/Services 42009, 495 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT RE//MIT^�TIED CASH RECEIVED eV DATE PERMIT' EH t}N(REV.i/xsi K r EH 14af v�'✓�