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APPLICATION SAN -oAQUIN COUNTY PUBLIC REA, VICES - ENVIRONMENTAL HEALTH DI I 445 N SAN JOAQUIN, PHONE (2 9 -3420 P O BOX 2009, STOCKTON, AW ( PERMIT EXPIRES 1 YEAR FROM A id�h UID (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. 54ayr16ID nd the Rules and Regulations of San a County Joaquin Coty Public Health Services. 16 f) d l0 Job Address -P)MA City Lot Size/Acreage Owner's Name r Address 1(0 17 11 -HOW I Q.-nd �� Pne Q Contractor II�Qf�{l�f• tt W� Address !03 No. nq PhonE __X d10 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XIMoq;I Well [] Qxr. Q 4 Sol-I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE UPtO Off FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS TIJr�, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ('I Public (-I Other n Delta Depth of Grout Seal IXCE�ilType of Grout 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 Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 applicant must call for all required inspections. Complete drawing on reverse side. t h Signed X�� 'Jam'_ — �—�z.� Title: rtart!! Date: a FOR DEPARTMENT USE ONLY Q Application Accepted by A./`/"'�"'�- 7 Date Z �p Area Pit or Grout Inspection by � - —` �t Date 5 /Z< q� Final Inspect' n by �`^'�J Date Additional Comments: �9. N Pf,0 ` 9 Applicant - Return all copies to: San Joaquin County Publc ealth Services Environmental Health Pe t/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. . EH1J•NIREv.iin51 Pa ©.f6� : e1 - >�1 EH t4•20