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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `,'r�/l ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 4��h' �� E,4 f P O BOX 2009, STOCKTON, CA 95201 CT� F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , PN /;4 (Complete in Triplicate) 9 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. .y Job Address ' �Y �� At> City Lot Size/Acreage Owner's Name _� ? � !A_M Address %lio �! - pw'l//o !V__* Phone ti 1/ / ?yZ-� Contractor llfee� D�LL�Nvf Address ,/�� 40!!w�/ 6*License No.IQS&�10 Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK Al/,P, SEWER LINES 1--o DISPOSAL FLO. A�& PROP. LINE 3O FOUNDATION _Lt?� AGRICULTURE WELL !� 4 OTHER WELL 6Y-4 PITS/SUMPS NA` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2"' ❑ Industrial OOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VDomestic/Private ,el'Gravel Pack ❑ Tracy Type of Casing10*�G- Specifications aa I"1 Public I.1 Other n Delta Depth of Grout Seal 6010.11 Type of Groutl&2'A74�*C I I Irrigation _.Approx. Depth astern Surface Seal Installed by �t 'C7tf�7 W=A, Repair Work Done U Type of Pump H.P. —_ State Work Dgqe _ Well Destruction O Well Diameter Z Sealing Material & Depth A9JVA,11-4.X N Depth Filler Material & Depth 423 S*_1P "mid I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ^ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number 11 .s: Number of bedrooms Character of soil to a depth of Water table depth SEPTIC TANK O Type7to pacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distaest: Foundation Property Line LEACHING LINE �Cl No. & Len of lines Total lengthFILTER BED Di ce to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lino DISPO AL 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." 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 parsons subject to workman's compensa- tion laws of California." The applicant call o uired ins ions. Complete drawing on .�I,rsse side. Signed Title Z,u �� Date: A-2,6J F R DEPARTMENT USE ONLY I Application Accepted by Date V` Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: /(�(� Applicant - Return all copies to: San Joaquin County Public Health Services' - � N-w Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK 9 CASH RECEIVED BY DATE PERMIT'NO. INFO . EM 13.21 1REV.v MW EH 11.2E