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APPLICATION SAN AQUIN COUNTY PUBLIC HEALTH RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQU IN, 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. 7 Job Address cC<��C�V''f �Z11C�.5ity City /��tff Lot Size/Acreage �L Owner's Name �44, G(. a` ('t .,GML�r Address rills.'X� LICU �L�^� Phone ZC7 94�j' — ✓ J'jG, a I+�j.A /;cc j7,11$f5f �lSL`fS Contractor !�' Ct[7/ r 'a�ddress �"�t-��l�l" License No. Vwpk Phone TYPE OF WELL/PUMP- NEW WELL F1 WELI REPLACEMENT 171 DESTRUCTION fl Out of Service Nell Cl PUMP INSTALLATION U SYSTEM REPAIR Ll OTHER X".. 1 Nottf bc,l#$ r�rI 1 DISTANCE TO NEAREST: SEPTIC TANK 3Ct SEWER LINES �Ct' _ DISPOSAL FLO. >�t PROP. LAVE >y,� FOUNDATION ICO AGRICULTURE WELL TL-t:- OTHER WELL Z""' PITS/SUMPS 72-c' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (I Domestic/Private Cl Gravel Pack 1-1 Tracy Type of Casing_.__-_ Specifications �,fn5 I'I Public ;<OtherX)fdNiii �Y I l Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Dbpth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _— State Work Done _ Well Destruction ❑ Well Diameter Z� Fealing Material Z Depth p Depth Filler Material i Depth _J'LekL,11 Sit l TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIIVADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 lest.) Installation will serve: Residence _ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ____._____.--__ Capacity____- No. Compartments V-j PKG. TREATMENT PLT. ❑ Method of Disposal - Dlslmrre to nenrelt Well Frnurdntlnn I"lopmty I III* t LEACHING LINE LI No. 6 Length of lines _ Total length/size FILTER BED CI Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS 11 Depth -----Size ___ — _ Number SUMPS 1.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be dune in accordance with San Joaquin county ordinances, state laws, an�� 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 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.fnust ca fo al'requ d inspeetions. Complete drawing on reverW�Z_ id Signed X « C�" —_— Title: clicDate. e1tCl FOR DEPARTMENT USE ONLY # � tpy/ Application Accepted by _ Date Area Fr �� l/y •-f d o't Pit or Grout Inspection by __ ate Final Inspection by Det Additional Comments: _ Applicant - Return all. copies to: San Joaquin County Public Health Services Environmental Ilealth Permit/Services ` V 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 VV FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. 1/ 7� INFO CASH • EH 13324INEV,risesZak �Ad EH 14 26 !J 2