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r APPLICATION • SAN JOAQUIN COUNTY PUBLIC HEALTH Sffi'VI'CS / ENVIRONMENTAL HEALTH DIVISION'. # pO 445 N SAN JOAQUIN, PHONE (209)468-P420- P O BOX 2009, STOCKTON, CA T20V �T 1 RES 1 YEAR FROM.A �Q (Complete in Triplicate) Application to hereby trade 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 Ban Joaquin county Putaic H)ealt�h�SServices. ( Job Address ��=� City Lot 91 se/Acrerge T Owner's Name ;J Address 1 ham e � Contract r Addie ��d e1��Clcense f JY,� Phone fI12� TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION Ll 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 .- 1bjjfNOEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS industrial ❑ Open Bottom Ci Manteca Dia. of Well Excavation T Dia. of Well Casing f-1 Domestic/Private Cl Gravel Pack7 ❑ Tracy Type of Casing__ Specifications I'l Public FI Other 11 Delta Depth of Grout Seal Type of Grout I 1 Irrlgatwn _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done tJ Type of Pump H.P. 3'p _—_ State Work Done Well Destruction O Wali Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 - REPAIR/ADOPTION ( 1 DESTRUCTION I I iNo septic system permitted it public sewer is available within 200 feat.) Installation will serve: Residence z Commercial— 0041 Number of living units: Number of bedroomsy�ENT Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg CaprLA No. Compartments PKG. TREATMENT PLT. O MAY 19 rNA Method of Disposal Distance to nearest: Well r>Zperty Lina RIA jyy LEACHING LINE C1 No. b Length of lines _ UYVIRONMENTAI I FILTER BED CI Distance 10 merest; Well Foundation _ Property i,, SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to merest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application end 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 petformonce 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 shell employ persons subject to workman's cturtpenae- tion laws of California." The applicant mus for rAl required speetions. Complete drawing on verse side. Signed ,� ( �gf Title; - - Date: �L G FOR DEPARTMENT USE ONLY Application Accepted by Date • ( A Area Ph or Grout inspection by Date Final Inspection by XQU4. / Date Additbr►af Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �03! Sovironmental Health Permit/Services 945 A San Joaquin, P O Box 2009, Stkn, CA 95 1 FEE AMOUNT DUE AMOUNT REMITTED C LVED ay DATE PERMIT NO. INFO l`Y�1 /AL1nI�/H . EN 1126 irtEv.ti� W et �t "rSL SCJ y✓l� J lel 3/V EN I4.y