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APPLICATION SAN JUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201C(0 711 PERMIT EXPIRES 1 YEAR FROG DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or inatall the work herein described. This application is made in conipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rule. and Regulations of San Joaquin County Public Health Services. 1r uLneJob Address �-=" `�� s _ City�.LL!�_k �n Lot Size/Acreage ! Owner's Name # Address y �� 1 6 �� Phone Contractor_ l Address '� '-t I icense No. Phone2L -C�cJ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION n Out of Service Well 0 �}1� ✓u PUMP INSTALLATION Q SYSTEM PAIR L� OTH Monitoring Well ❑ D16TAN E TO NEAREST: SEPTIC TANK 1' SEWER LINES�1 DISPOSAL FLO PROP, LINE/ FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia, of Well Casingly w� Domestic/Private Cl Gravel Pack I-) Tracy Type T �~ '� of Casing_ Specilications Others Delta Depth of Grout Seal Type of Groulee,46A, a�da4% I Ir6galion Y Approx. Depth f I Eastern Surface Seal Installed by � Repair Work Done U Type of Pump H.P. _.__._ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAMIADDITIr)N ( I DESTRUCTION I I INo septic, systorn permitted if public sower is available within 200 feet.) 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 PKG. TREATMENT PLT, f1 Method of Disposal Distance to nearest: fell) Foundation Property Line LEACHING LINE 0 No. & Length of lines _ Total length/sire FILTER BED CI Distance to nearest: Wall Foundation Property Line SEEPAGE PITS 11 Depth Sire _._ Number SUMPS t_! Distance to nearest: Wel _ Foundation Property line DISPOSAL PONDS ❑ I hereby certify that I have prepared ibis application and that the work will be done in accordance with San Joaquin county ordinances, state Iaws, and rules and regulations of the San Joaquin County Home owner or licensed agent's iignature 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 porlofmance 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 forI require inspec ' ns. Complete drawing on reverse sid 77 Signed X ' Title: � s`t Data: 3 ___ v y � FOR DEPARTMENT USE ONLY Application Accepted 4y ,W! _ Date t} Z ` Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return R11 copies to: Snn ionquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOVNT DUE AMOUNT REMITTED CASH RECEIVED BY INFO l� DATE Q q PERMIT NO . EN14.2d3 24 IREV_riMSr LJ Vq eQ �O �lJ �Ip —� W ` �Z!' FH 11 ie ~