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APPLICATION IN COUNTY PUBLIC HEALTH SERVICES IRONMENTAL HEALTH DIVISION JOAQUIN, PHONE (209)468-3420 AL 2009, STOCKTON, CA 95201 - TRES 1 YEAR FROM DATE ISSUED omplete in Triplicate) • hereby made to Sam Josquin County for a permit to construct and/or install the wort herein described. This application is made in compliance with Eton Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Publics Health Services. p/� AJ� Job Address � ,Z,� 5 (70 1114 L�l�-- C7ry/Z",L,�K� Lot Size/Acreage Owner's Name ��yy e D r, Z A Address , l,o .4.QTL JCC1 P p n> _ Phone �[ Contractor 4c )511 L{��Address PafJ 2t7 o4AOTiy t License No.O2/k��Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION C SYSTEM REPAIR D OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C; industrial [I Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing Ci Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I") Public ):1 Othaf 1-1 Delta Depth of Grout Seai Type of Grout 1 I Irrigation Approx. Depth I I Easrerr, Sufface Seal Insrailed by Repair Work Done ❑ Type of Pump H.P_ __ State Work Done _ WNI Destruction ❑ Well Diameter Sealing Material A Depth <-- Depth Filler Material • Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONDESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence-L--l"Commerciet_ Other Number of living units: _/-- Number of bedrooms Character of saU to a depth of 3 feet: Water table depth SEPTIC TANK I] Type/Mfg Capacity No. Compartrronts PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE j7lNo. & Length of lines _ t" Total length/sail FILTER BED C1 Distance to nearest: Well AL Foundation cA2 Fes` Property Line -325 F� SEEPAGE PITS I II Depth GT Sue �d Number r/ SUMPS IE7 Distance to nearest: Well��``Foundanon Property Line d�� DISPOSAL PONDS ❑ 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 signature certifies the fomowing: "I certify that in the performance of the work for which this permit is issued. I sham not/-�— employ any person in such menrw. As to become subject to workman's compensation laws of California."Contrecior's hiring or subcontracting signature certifies the fol0wing: "I certify that in the performance Of the work for which this permit is issued, 1 shall employ persons subject to workman's utmpansa- tion laws of California." r The applicant must eaq for I requ ed inspections. Complete drawing on reverse side. Signed X,._ s ,�, Title: 777—� Date: ^L_�C FOR DEPARTMENT USE ONLY Application Accepted by _ C ' O Dat Areams _ Pit or Grout Inspection by Date Final Inspection by Dattl1j� Addition*; Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services T 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE ()� INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PE ✓' 1j //� �J p_^r/ 1�j/ EK 13-74 IR » fY.t! 17 /rye i /V EH 1 4.7a