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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ? PERMIT EXPIRES 1 YEAR FROW DATE ISSUED . (Complete in Triplicate) Application In hereby trade t:o 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. 5L9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �51 � i� � City ALJ:7A�Z Lot Size/Acreage Owner's Name 1 t�' ( � N� Address �c '-i qyE Phone Contractor Address, N. 6?VAE-License N2�� Phone-420 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well O 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 Cl Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing [1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications Il Public CI Other Cl Delta Depth of Grout Seal Type of Grout - I I Irrigation __Approx. Depth I I Eastern Surface Saul Installed by ti. Repair Work Dons U Type of Pump H.P. --- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i DESTRUCTION I I INo septic system permitted if public sewer is available within 200 tsar.) Installation will serve: Residence Commercial_ Other . Number of living units: _JL_ Number of bedrooms Character of soil to a depth of 3 feet: �f�F�� Water table depth SEPTIC TANK-�$J"❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines 7— Total length/size ! FILTER BED n Distance to nearest: Weltdy� Foundation /2` Property Line SEEPAGE PITS 11 Depth ,e !� Size J X F Number f S� SUMPS Distance to nearest: Well 'f- Foundation Property Line 2 DISPOSAL PONDS ❑ y I 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 a' nature certifies the following: "1 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 applicanIquist call for oil r uir ns tions. Com to drawing on reverse side. Signed Title: r Date: OR DEPARTMENT USE ONLY Appl' ion Accepted by c4,,, �L . �.a " Date ��3 q� Area or Grout fns ction by �JF�,��t�,slt .Date W14� Final Inspection by. T-i n Additional Comments: / Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Boz 2009, Stkn, CA 95201 FEEi INFO AMOUNT �rDUE � AMOUNT REMITTEO CASH / RECEIVED BY DATE PERM17-N0. EM ti3-24 1REV.I/w v tj {J 1 l7 _ I EM 142e