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APPLICATION r1 SAN JOA QUIN COUNTY PUBLIC HEALTHERVICES ENVIRONMENTAL HEALTH DIVISION 445 N[ SAN JOAQUIN, PHONE (209)468--3420 P 6 -BOX 2009, STOCKTON; CA 95201 1 i ;I PERMIT EXPIRES X 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 in 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 O(.<L S G City/_-r.� o Lot Size/Acreage Owner's Name Tr~ �� Address C16 4 a�� Phone T Contiactor�- �rV Address l �f License No. ��,- 2,C) P h o n 4121171 151�slr+ TYPE OF WELL/PUMP: NEW WELL ❑ t. WELL REPLACEMENT .n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ,C1 OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom O Manteca A Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private C1 Gravel Pack n Tracy Type of Casing__1ZL Specifications i'I Pr blic 0 Other 171 Delta Depth of Grout Seal 3 Type ype of Grout r+-w--- J--- I I Irrigation _.Approx. Depth 11.Eastern ',) Surface Seal Installed by__ __Qr5 Repair Work Done 13 Type of Pump H.P. State Work Done _ Scre_ Well Destruction 1:1 Well Diameter Sealing Material & Depth Urn r ci Depth Filler Material & Depth . -4 ! .f TYPE,OF SEPTIC WORK: NEW INSTALLATION !'.1 REPAIR/AUDITION I I DESTRUCTION i I (No septic system permitted if public sewer is ��. available within 200 fest.) Installation will serve: Residence — Commercial_ Other Number of living units: Number of bedrooms l! Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i1 Capacity No. Compartments PKG.`TREATMENT PLT. ❑ Method of,Disposal Distance to nearest: Well t' Foundation Property Line LEACHING LINE El No. & Length of lines !I Total length/size FILTER BED C) Distance to nearest: Well � Foundation Property Line SEEPAGE PITS 11 Depth Site Number SUMPS Ll Distance to nearest: Well ' Foundation Property Line DISPOSAL PONDS p , I hereby certify that I have prepared this appiicatioWand 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 L employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 1F 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 st c req it ins cli omplete drawing on reverse side. 31� Signed X 'Date: f7-• _`9 r 1 FOWDEPARTMENT USE ONLY I` Application Accepted by � Date �1 7 Area Pit or Grout Inspection by Date Final Inspection by Date Additlonal Comments: 9. Applicant - Return all copies to: San Joaquin County Public Ilealth Services Environmental Health Permit/Services V 445 N San 'Joaquin, P O Box 2009, Stkn, CA 35201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMtI N0. CH 3.24 { 5y 4 P G • EIit1.�aIRE V.Ein51 '� ' .: q`-'rl a