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# APPLICATION SAN QUIN COUNTY PUBLIC HEALTH UVICES l ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 r P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I 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 1n compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address adz- �"� City � ��o h Lot Size/Acreage *S J 5 ¢ ••r Owner's Name 9. M'e"r �er� c- �Address 1-11._1W:5_%+u.t 'l `\�`�' L Phone Contractor SPc�-�` - r"' t-�i��? --Address 7-5L'S f • M-Yr�\C- __—License No. 117-Z66 Phone Ltk5y 12QZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER Monitoring We ❑ DISTANCE TO NEAREST: SEPTIC TANK iG� r SEWER LINES ' DISPOSAL FLO. uQ ' PROP. LINE «' FOUNDATION Lq AGRICULTURE WELL 3:r4- OTHER WELL_ R:_-_' PITS/SUMPS �r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ~, 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 16 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ('1 Public 3 Other n Delta Depth of Grout Seal Type of Grout N-.A I I Irrigation tJ Approx. Depth i%k Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. St to Work Done _ �A Well Destruction 0 Well Diameter � Sealing Material i Depth twn�^n t G-'k4 Depth Filler Material A Depth C--4d>i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR1AODtTION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other 1 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 PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE ❑ No. A Length of tines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 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 ust/ccc 11 f all required inspections. Complete drawing on reverse side. / / Signed X_�{[J� 4 Title: 5e-1".-- ��' Date: S/ ��< 1 FOR D PARTMENT USE ONLY 1 �� Application Accepted by ta= Dais—% Area Pit or Grout Inspection byy"�, ,fi/' L Date,✓ Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services _ Environmental Health Permit/Services S 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 EEE AMOUNT DUE AMOUNT REMITTED CK s RECEIVED BY DATE FERMI7-NO. INFO q ^ ,yC�A(SH j . E813-24 1riEV,1/n Si •� O O 91 - .. g EM 14.76 a