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APPLICATION SAN- JOAQUIN COUNTY PUBLIC HEALTH4SERVICES ENVIRONMENTAI ' HEALTH DIVISION . .445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCgTON, CA 95201 ' PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED (Complete in.,Triplicate). „ Y Application ks� herebylmade to San Joaquin County £or a permit to construct and/or install the work herein described. This applicntionjis'Imade in compliance frith San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San Joaquin Courity,, Public Health Services. , I p r r Job Address Y v City. 0D Lot Size/Acreage Nam 1.7 Owner's e i D K „Ol t k►J O>`.1 Address'. a`Q. t71 D L. b9— Contractor Q Phone s - — Contractor t�� P S E> Address 7+(a0 9 4D% F 'icense No. Phpne2oi— Zq_Q� TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well '. DISTANCE TO',NEAREST;.SEPTIC TANK -. SEWER LINES COO DISPOSAL FLD. ' PROP. LINE H FOUNDATION AGRICULTURE WELL. OTHER WEL ' PITS/SUMPS _ INTENOEDIIUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F Industrial it ❑ Open Bottom ❑ Manteca Dia. of-Well Excavation Dia. of Well Casing Cl Domestic/Pr,ivete' ❑ Gravel Pack ❑ Tracy Type o1 Casing ^ Specifications I'I Public `KI Other r A n Delta, Depth of Grout'Seal s'�g Type-af Grou/It 't'�' I I Irrigation ; "�,�.Approx. Depth 1 Eastern Surface"Seal Installed by �(�Slt__ tsrlt_,t, W`e4( COf�►'_ Repair Work Done. 0 ;;Type of Pump H.P, �L ' State Work Done _ Welt Destruction O Well Diameter g4f Sealing Material & Depth Depth 76 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I k 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 soil to a depth of 3 feet: ; Water table depth SEPTIC TANK. ,x ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 i. Method of Disposal tl rr i= Distance to nearest: Well Foundation Property Line. Ji i= LEACHING UNE ,, Cl No. & Lengtf of lines c Total length/size FILTER BED ? Gl Distance to nearest: Well - Foundation Property Line , b SEEPAGE PITS: E I Depth Size ? Number SUMPS Ul Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certifythat 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 orlllicensed agent's signature certifies the following: "I certify that"In the performance of the work for which this permit is issued, I shall not I 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, l shall employ persons subject to workman's compensa tion laws of Cal'ornia." The applicant usi II fora a wired inspections. Complete drawing on reverse side. F , 12 Signed X-- - Title: "t*� � Date: 3 wP - FOR DEPARTMENT USE ONLY _ST Application Accepted by '?_ Date Area Pit or Grout Ins Ipaction by Date Final nspection by Date Ltd i t%LYAdditional Comments: st - ao Applicant Return all copies to: San Joaquin County-Public Health Services �I Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201. FEE AMOUNT DUE AMOUNT REMITTED CK SN € RECI IVEp BY" DATE F?ERMIT NO. INFO, CA �rII1�a • 1 - [/g ; .� EN /Z0(REV „ ' - LIT()oU _ Q '