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D APPLICATION I CATION PERMIT EXP�AA 00�0COUNTY PUBLIC HEALTH S permit may have expired without ENVIRONMENTAL HEALTH DIVISIO SAN work being completed or InspeA JOAQUIN, PHONE (209)46 -um 10 g p BOX 2009, STOCKTON, CA 95 by Environmental Health DIPision 4111111111111 - ERMIT EXPIRES 1 YEAR FROM DATE (Complete in Triplicate) Application is hereby made 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 San Joaquin County Public Health Services. < t ?7 Job Address city ' / Lot Size/Acreage Owner's Name L'C(-ii% 0� &/�Adqdress �( �(O , // r Phone Contractor -�%SIL Address �CZSa r - ,/ License No. Phone uf- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE F] Industrial CI Domestic/ Private I') Public I I Irrigation Repair Work Done U Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Gravel Pack (-.1 Other __ Approx. Depth Type of Pump _ Well Diameter _ Depth ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing - 1 -1 Delta Depth of Grout Seal I I Eastern Surface Seul Installed by H. P. _ State Work Done _ Sealing Material i Depth Filler Material i Depth Dia. of Well Casing Specifications Type of Grout VVUHK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg PKG. TREATMENT PLT. ❑ Other Capacity Distance to nearest: Well Foundation LEACHING LINE Cl No. b Length of lines FILTER BED ❑ Distance to nearest: Well SEEPAGE PITS I I Depth Size SUMPS LI Distance to nearest: Well DISPOSAL PONDS ❑ Water table depth _ No. Compartments Method of Disposal Total len Foundation pJ�y�11� Foundation TY 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 following; "I 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 workmen's compensation laws of California." Contractor's hiring or subcontracting 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 appli m st call for all requ' spsctions. Complete drawing on reverse side. Signed Title: _ Date: FOR DEPARTMENT USE ONLY / Application Accepted by 1 Z Date Area Pit or Grout Inspection byr ^ ^ Date^ ` Final InspecAion bye • Date Additional Comments: Applicant - Return all copies (' SEE AMOUNT DUE �1^ L INFO • EH 11-24 (REV. 1 / n sl —7 FM 11-M [ r San Joaquin County Public Health Servi gs V 0 L Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 AMOUNT REMITTED K RECEIVED BY CA H DATE PERMIT N0. —7L IC—F112 1 "-V_ - I ,/_ .I .r _ _ r