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APPLICATION SAN JOAQUIN COUNTY PUVLIC HEALTH SERVICES ENVIRONJ[ENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 COP PERMIT EXPIRES 1 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 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. / Q / '� rJ J�Job Address 7 3 7 N,�w�g s�1 !\c f City!:5 rl Lot Size/Acreage /1 Ow// / "K f' �wner't Name J4[ ` I r� Address Phone IAContractor ©t�tl F� Address 5— wl -- License No. Phone `TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT t•1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Nopitoring ell C� j 4 CeOSS(ONN SQJ DISTANCE TO N AREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P OP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED U$E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well,Casing ` I I Domestic/Privslte Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications vV 11 Public 1-1 Other 11 Delta Depth of Grout Seal Type of Graut I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done, U Type of Pump H.P. _— State Work Done _ r Sealing Material i Depth Well Destruction ❑ Well Diameter Depth Filler Material i Depth 0 TYPE OF SEPTIC ORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system pwmitted'if public sewer is (� I available within 200 feet.) Installation will servo: Residence_ Commercial_ Other Number of living units; — Number of bedrogme Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK i ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line / LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS i LI Distance to nearest: Well______ Foundation Property Line DISPOSAL POND4 ❑ 1 hereby certify thrt I heave prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulaligns of the San Joaquin County Home owner or ligpnsed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any perso in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foAowfng: "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 CalifQ1nls." The applica mut all for all r ired in�peclions. Complete drawing on reverse side. / `�-` Ksigned LT__�� —�4�� Title: 46U-�Gl Data: � 13 1 FO DEPARTMENT USE ONLY /7rtZ 1 1R Application Accepted by Date Area S� fPit or Grout Inspis tion by Date Final Inspection by Date r � Additional Comn4nts: Applicant T Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED JRECEIVED BY DATE PERMIT'NO. INFO /CA�J�� /� 4 Ali.' �r ,(�,°I� ., r vi^, r .( `T i 1 ice' R+/ ,. `• i�