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APPLICATION FOR PE SAN JOAQUIN COUNTY PUBLIC HE TINb�sftVICES ENVIRONMENTAL HEALTH DI �M'446$N�420 445 N SAN JOAQUIN, PHONE (2 i P O BOX 2009, STOCKTON, ��S2Q1 \ti PERMIT EXPIRES 1 YEAR FROM I S (Complete in Tripli Q' Application is hereby made to San Joaquin County for a permit to construct and/or insta n T Ss application In made in compliance with San Joaquin County Ordinance No. 549, and 1862 and the Rules and Regu n Joaquin County Public Health Services. / y� Job Address / /�► �1Ld Aj.,10e '/7414ICity 5 0<X/d*}/ Lot Size/Acreage Owner's Name ��G 1k0;-SAN Address p""y61 Phone Contractor �4 �� SG Address �04� AJC&!' LJV License No. sem'11 "� Phone X�–r a4( �' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION Ll Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing r Domestic/Private D Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public I-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Easfarn Surface'Sedl Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth b Filler Material i,Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION,I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other rldb� �,Or& Number of living units: _/— Number of bedrooms Character of soil to a depth of 3 feet: eG.4y Water table depth f r� SEPTIC TANK ❑ Type/Mfg A'W CAfr Air L. Capacity �i'flJO No. Compartments � PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line G LEACHING LINE �1[' No. 8 Length o1 lines � �0 � olio) length/size � FILTER BED ❑ Distance to nearest: Well /XS� Foundation d Property Line SEEPAGE PITS VII' Depth Size a� Number X SUMPS LI Distance to nearest: Well /aS� Foundation lf� Property Line �0 0 • DISPOSAL PONDS Cl 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 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X /%� >� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by C r Date h la TArse cXJ9--3 { rout Inspection by C Date Final Inspection by Date lL Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNTITTED RECEIVED 8Y DATE PERMIT NO. INFO CASH H14-21IREV.rinS1