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APPLICATION - SA' tAQUIN COUNTY PUBLIC HEALYICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 M PERMIT E%PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby merle to San Joaquin .County for a permit to construct and/or install the work herein described. This application is made in couplisnee with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. City 44,r&-y, Lot Size/Acreage Job Address ., � � .t; l L "•+ �...•.� � ��-•,�<'•./P Phone 1 , _ Owner's Name - Address Contractor ddress > >' cY- ir/-L✓1 . J License No. �i �FC1 7� _Phone /:>� �• TYPE OF WELLIPUMP: NEW WELL El SYSTEM REPLACEMENT n DESTRUCTION ❑ out of Service well Ll SYSTEM REPAIR EDOTHER ❑ Monitoring veil PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS1SUMPS �- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom r 0 Manteca Dia. of Well Excavation n�- -� < Dia. of Well Casing Dd DomasticlPrivate Gravel Pack ❑ Tracy Type of Casing 4e.A 0 P P Y, .— Specifications ("I Public nQ Other AppaK. Depth I I Eastern �ther 11 Delta Depth of Grout Seal Type of Grout i I Irrigation Z- p � rSurface Seal Installed by •— Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter !1 -,r �.i{„ Sealing Material,& Depth Lz��-� w S 3 x°^^��`` L U-66' Depth F' Filler Material & Depth b 3 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I lNo 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 soil to a depth of 3 feet: Water table depth A SEPTIC TANK O Type/Mfg Capacity No. Compartments 1 �1 PKG. TREATMENT PLT.❑ - Method of Disposal J Distance to nearest: Well Foundation—.Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line v 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: "f 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." F The applicant must call for all required inspections. Complete drawing on reverse side. Signed X� h'/moi�(_ cx�""-" - _._ Title: 1,/ /Nc."�p-i`�r�<"-' Date: FOR DEPARTMENT USE ONLY f Application Accepted by Date �v Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments. I, �/ 7 Applicant - Return all copies to: S VVI.quin County Public health Services ❑ Environmental Health Permit/Services I !� 945 N San Joaquin, P O Box 2009, Stkn, CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVEq Y DATE PERMIT'NO. INFO CASH ,gyp EH 1�4,tnEv.,,Msr M� �'9 1719 /�• 92-rtDs � EN 74.25 !•,