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APPLICATION �Y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BO% ;2009, STOCKTON, CA 95201 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 ►cork herein described. This application is made in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. rte, Job Address !" Sffmft LVA' �f City Lot Size/Acreage Owner's Nam Addrtess'= V I/'•'` A1�t'��Y C' Phone L r J s�0 -- y� �,{ � 1 I 40'73(o _C �1 Contractor V - �� Hddress V I:� Lti v License No. Phone l B3fr l TYPE OF WELL/PUMP: NEW WELL C1 I WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 0 FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C) Domestic/Private 5taveI Pack ❑ Tracy Type of Casing-_.____U� Specifications I'I Public Ell Other f'1 Delta Depth of Grout Seal Ld __ Type of Grout P40w4vib I i Irrigation —Approx. Depth A(Eastarn Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. __ State Work Done Weil Destruction ❑ Well Diameter Sealing Material 6 Depth 7a��-t2 Depth Filler Material i Depth -.*-3 nj� 71- 2r S TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION 1 II DESTRUCTION [ I INo septic system 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines 4 Total lengthtsize FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation 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 ordinances, state laws,-and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: ••t certify that in the peiformance 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 applica ust II It required i pections. Complete drawing on rreev�erlse side. Signed Title: '` --- - Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by nate Final Inspection by Date Vf Additional Comments: S I Applicant _ Return all copies to. San Joaquin 4ounty Public Health Services Environmental Health Permit/Services ,✓)V ` 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMtTtED CK AECEIVEO BY DATE PERM17'NO. INFO .�7 CASH .,j / �} �+ . EH 1 2.24 IREV.rinai JC r 3dZ5 f�� (O ! t 033x,3 EH t4.20 C� .. .r-�_ ' �a.r.r:�ti.`r«. �.r'i w- �.....'rV.r..r�w-•Y t.r.r�..`..r is' i �