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APPLICATION SAN (,,.o1QUIN COUNTY PUBLIC HEALTH�"RVICES ENVIRONMENTAL HEALTH DIVISIM 445_ N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EgPIRES I YEAR FROM DATE ISSUED• (Complete in Triplicate). Application is hereby msde,to San Joaquin County for a permit to construct and/or install the work herein described. nus application is made in Compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules Joaquin County Public Health Services. and Regulations of^ `d0 �o Job Address City Lot Si ze/Acreage Owner'$ Name ffazr=�ei-rk_ L 0102 =�- Address dy 12i ly.I Phone - Z„ IJ Contractor i0 ` Address f� �3 1 i V S �, License No.71 60 74 _Phone 7C 7 37 TYPE OF WELL/PUMP: NE ELL ❑ WELL REPLACEMENT 0 DESTRUCTION Xf Out of:Service Well J$j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well © i DISTANCE TO NEAREST: SEPTIC TANK ICJ(fi e SEWER LINES /1/ _ DISPOSAL FLO. ./ — PROP. LINE !d FOUNDATION 6D AGRICULTURE WELL OTHER WELL",•`� PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 industrial ❑ Open Bottom CD Manteca Dia. of Wel! ExcavationDia. of Weil Casing Cl Domestic/Private ❑ Gravel Pack- ❑Tracy Type of Casing S Specifications i f'i Public M Other 171 Delta Depth of Grout Seal Type of Grout c'11�N, I i Irrigation _Approx. Depth I ! Eastern Surface,Seul Installed by ! �Cnesi," Repair Work Done 0 Type of Pump H.P. f State Work Done_ Wel! Destruction f Well Diameter Sealing Material & Depth Depth Filler Material U Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION t I.,DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial — Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: j SEPTIC TANK. © Type/Mfg '` Capacity � No. Compartments PKG. TREATMENT PLT.d Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: 2, Well Founcaiion Property Line :4" SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest:" Mill, Fbundatian 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.ordinancasr $tato latw•, ,na rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 certify-that in the perf6rmancs.of the work for which this permit is issued, I shall nci employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring at sub-contracting vgnuturG certifies the following: "I certify that in the performance of the work for which this permit is issued, I$hail emplay persons subject to workman's campcnMg tion laws of California." The applicant must call for alt ired inspgcti ne. Compt drawing on reverse side. .4 itle: Signed Date:" FOR DEPARTMENT USE_O LY. - s Date Area Application Accepted by f Av�cAf Date �Finaltion by r AA 4--e%� - Date f O Pit or Grout Inspection by .�� _ Additional Comments: Appl"icant - Return all copies to: San Joaquin County Public Health Services . Environmental Health Permit/Services ' 445 N San Joaquin, P O Box 2009, Stkn,CK� 'QA 9520E L^� 3 IFEE NFO AMOUNT DUE AMOUNT,R£MIT'TEO CAS RECEIVED BY DATE PERM�17'NO. Page y3( . EH! 3-24(REV. {001oo d EH 14-Z