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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. I Job-Address < 5 �C City e/�RlLot Size/Acreage Owner's Name a-,,-1-<A _ At(/ S Address -Phone Contractor �� /ci�� rQ Address ' Liceseo � �Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service well ❑ PUMP INSTALLATION O 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 O Industrial O Open Bottom u Manteca Dia. of Well Excavation Dia. of Well Casing C.1. Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications \f} '1 Public Cl Other n Delta Depth of Grout Seat Type of Grout 11 I I Irrigation —Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done i_] Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material 3 Depth �J Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is r- _� available within 200 feet.) V Installation will serve: Residence If Commercial_ Other /v' Number of living units: __/__ Number of bedrooms� b A Character of s � oil to a depth of 3 feet:—- - u A r !/ f.Q PV Water table depth SEPTIC TANK ❑ Type/Mfg _ � Z Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ ( �! Method of Disposal Distance to nearest: Well G Foundation Property Line LEACHING LINE -,iK No. & Length of lines7 O �� Total length/size 7- FILTER FILTER BED O Distance to nearest: We1142= Foundation Property Line L t SEEPAGE PITS 1 I Depth ��_5ize -- 5?-41a I X � Number �1 SUMPS )Q Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws, and rules and regulations of the San Joaquin County t� 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 S_ employ any person in such manner as to become subject to workman'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 applicant must call f r all required inspections. Complete drawing on reverse side. �f Signed X:� Title: Date: FOR DEPARTMENT USE ONLY �] L� Final Inspection by Application Accepted by Date + - r + Area // Pit or Grout Inspection by Date L� Date Additional Comments: —�I�Y7�/�f X Z12 {� Applicant - Return all copies to: San Joaquin County Public HealthServices Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 9E) AMOUNT DUE AMOUNT REMITTED CK t R tV D GATE PERMIT NO. CASH • EH 1324(REV.,,m5) •� "'% A c-Q I EH 142E [ f�J t ` t b