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APPLICATION _ SAN- JOAQUIN COUNTY PUBLIC 'HEALTH SERVICES q VISION ENVIRONMENTAL DI 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED (Complete in 'Triplicate) Application'la hereby made.to San Joaquin County for &.permit to construct and/or install-the work herein described. This application is made in cozwliance with San Joaquin County-Ordinance 'No: 50 and 1862 and the Rules and Regulations of Sen Joaquin County Public Health Services. Job Address '1 '�D F ' L City_ 41 iib D (__ Lot Size/Acreage I - Owner's Name` E� Address SO ED&t atop L• Phone Z 04 Contractor sldr A �Addre53 7U(e0 �� t100 N°� Litense No.`+� V r Phoneme/V'`+`��' �3 TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMENT n DESTRUCTION Cl out of Service Well CI PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monitoring Kell DISTANCE TOINEAREST SEPTIC TANK SEWER LINES .'/�O' DISPOSAL FLD. PROP. LINE ZO'r FOUNDATION AGRICULTURE WELL OTHER WELL ZSf7 - PITS/SUMPS INTENDED,,IUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r i f Well Excavation. Dia. of Well Casing .2 0.Industrial , ❑ Open Bottom ❑ Manteca D a o A VC c C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Other CirArb fl Delta Depth of Grout Seal �1 r _ Type of Grout or t 1 tr6gation -OApprox. Depth 1yC Eastern Surface Saul Installed by l us k4=4 . Repsir Work Done U Type of Pump H.P. .. State Work Dane p" � Sealing Material & Depth Well Destruction' ❑ Well Diameter f1 Depth Filler Material L Depth TYPE OF SEPTIC,WORK: NEW INSTALLATION I I REPAIR IADDITION f I DESTRUCTION l 11No septic system permitted if public sewer is available within 200 feet.) t, 1 Installation will serve: Residence. Commercial Other Number of tieing units: Number of bedrooms Character of',soil to a depth of 3 feet: Water table depth SEPTIC TANK:'. .0 Type/Mfg 'Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal , Distance to nearest: Well .. Foundation Property Line. LEACHING LINE ❑. No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth msizq - Number F SUMPS LI Distance to nearest. Well Foundation Property Line . DISPOSAL PONDS l3 1 hereby certify,that I have prepared this application and that the work will be idone 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.parformance 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 61 the work for which this permit is issued, t shall employ persons subject to workman's compensa- tion,laws of California." 6 The applicant " ust ail far all required inspections.' Complete drawing on reverse sidd / iL Signed x Title: ro ` ��i 3T Date: I� Q FOR DEPARTMENT USE ONLY ST27 Application Acc -epted by Date T Area +tel V- ri Pit or Grout Inspection by Date Final Inspection'by Date , Additional Comments: - Applicant - Return all copies to:' San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEEAMOUNT DUE AMOUNT REMITYEO CK -RECEIVED BY DATE PERM17'NO, !INFO AMOUNT CAS>♦; .-.{}. G ��}�--��- . EH t7.28)REV,r i�31 WM 1 � !!• � �' / + 4 tet./✓,/J - EH t4.2e