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APPLICATION .we S40/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388,STOCKTON,CA 95201-0388 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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. D W4T r c- 3 % 11��_ Job Address �� 5 L hh� ��q. City � a Lot Size/Acreage _ � Owner's Name L B I e- Address 1?-0. Bon 1119 - Phone G �5(,,1 Contractor �,5 S p>•i 111' ddress _ License No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER X Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 300 SEWER LINES -70 DISPOSAL FLO. PROP. LINE 10 FOUNDATION ___iD_ AGRICULTURE WELL OTHER WELL 13 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation IS Dia. of Well Casing Domestic/Private ❑ Gravel Pack IX Tracy Type of Casing_ Specifications I'l Public 0 Other Fl Delta Depth of Grout Seal 3S Type of Grout ��T GtyJICd I I Irrit)ation ` S'Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 T�y�fytPP H.P. —_ State Work Done_ Well Destruction ❑ Main Diafieter 1 Sealing Material i Depth Depth_ - -i, i 3 S f Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I 1 (No septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Charactef of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PET. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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." Contractors 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: t0 log 1 S 1 Date: ;Z - 7-q 5 FOR DEPARTMENT USE ONLY �" - Application Accepted by Date tea` «- -Area Pit or Grout inspection by Date z�NS Final Inspection by Date Additional Commsnts: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 m CK a FEE INFO AMOUNTj�DUE AMOUNT REMITTED CASHJ�REECEIVED BY DATE ^r PERMIT NO, � . EH 13•24(REV.i/M 51 EH 14'.28