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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH �„�7 ENVIRONMENTAL llEALTH DIVISI N --tt 445 PN OBOX SAN J2009, STOCKTON, CCAOAQUIN, PHONE )95 A§ 7 757 7 PERMIT EXPIRES 1 YEAR FROM DATE IfiW (Complete in Triplicate) # Application is hereby made to San Joaquin County for a permit to construct and/or athEs application is made in compliance with San Joaquin C unty Ordinance No. 549 and 1862, and the Nules and liegulations of San �( Joaquin County Public Health Services. 1 Job Address �` City Lot Size/Acreage Owner's Name L4, A`�ffesi9 �r Phone f31-5-16-7 Contractor Address License No. Phone_ / TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT LI DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR Ll OTHER O Monitoring Well 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 f_1 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing f l Domestic/Private O Gravel Pack L) Tracy Type of Casing__-_.____ Specifications 1'1 Public 1-1 Other 1*1 Delta Depth of Grout Seal Type of Grout I I IrriOation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. _-_ State Work Done _ Well Destruction O Well Diameter Sealing Material ii Depth m Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONI I STRUCT�IO_Nd septic system permitted if public sewer is v ailable within 200 lest.) ' 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. b Length of lines Total length/size FILTER BED CI Distance to nearest: Well _ Foundation _ Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS 1_1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 persons subject to workman's compensa- tion laws of California." The applican us call for all req inspecti s. Complete drawing on reverse side. / ll r q_ Signed X c� e) Title: Date: L R DEPARTMENT USE ONLY 3 ) Application Accepted by Date �` _ Area r / Pit or Grout Inspection by ate Final Inopection by Date Additional Comments: CotK Appiicnnt - 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 NIG Glt�d �i + FEE AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT NO. INFO ''LASH EH 13 N IREV.I/n sr C0 t"l�'� 7 V EH 1,.2E -- p