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APPLICATION SAN JOAQUIN COUNTY PUBLIC AftER ENVIRONMENTAL HEALTH IN 445 N SAN JOAQUIN, PHONE IC� q 8-34 P O BOX 20091 STOCKTON 2O1PERMIT EXPIRES 1 YEAR FRO ISSUED (Complete in Tripl ' c ` Application is hereby made to San Joaquin County for a permit to construe or nstall the work herein described. This application is made in conpllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address / CJ U -s• I�CU� ► G t City 1410 Lot Size/Acreage Owner's Name d �y''�'1 Address -/ gr s' ��'/��'-��GK s Phone _ z L elel Contractor /► �f/� Address 21 / Cr License No. Z7�2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION P( SYSTEM REPAIR O OTHER ❑ Monitoring Well Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing qJ JK Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Dept/h � 1I1-Eastern Surface Saul Installed by Repair Work Done U Type of Pump —.2SG(� H.P. 3 State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Distance to nearest: Well Foundation PropertA GG VIEM LEACHING LINE Ll No. b Length of lines Total length/s� FILTER BED ❑ Distance to nearest: Well Foundation t AUC"ur'S r I1' SEEPAGE PITS 11 Depth Size N N SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with Sari 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 workmen'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 persons subject to workman's compensa- tion laws of California." The applicant m t II for I required Ins cti s. Complete drawing ohreverseside. q Signed X Title: ' J-etaeZ�__ i��L?1" Date: / FOR DEPARTMENT USE ONLY Application Accepted by Date 9 Area Pit or Grout Inspection by Date Final Inspection by Date, Additional Commants: Applicant - Return all copies to: San Joaquin County Public Health Services }environmental Health Permit/Services 445 N San Joaquin Box 2009, Stkn, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED C H RECEIVED BY DATE PERMIT NO. • EH 1321(REV.I/AS) 14 EH14.2a qq