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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.::' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 /J 0 L 0 9 1992 P O BOX 2009, STOCKTON, CA 95201 EMV1,; NNilLENTAL H L T h PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERV;rF_5' (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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Y1111.0 Job Address T 90 F/'1'71 6r� ��'�� City� Lot Size/Acreage Owner's Name eA edk;f AIy Tr"S,((Address 044_ &OxrP411A WFft"C Seo Phone Contractor WES1. HW4-TVf� + Address 13153 S I�IQi M. U, -E 1�' icense No. 559 "971 Phone ?9,M TYPE OF WELL/PUMP: NE WELL Iq LI) WELL REPLACEMENT 7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION L� SYSTEM REPAIR ❑ 1OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES l SD" DISPOSAL FLO. — PROP. LINE FOUNDATION _�[� AGRICULTURE WELL _V_L_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation icr Dia. of Well Casing F..) Domestic/Private ❑ Gravel Pack 17L Tracy Type of Casing_ c- Specifications I'1 Public (1 O her (1 Delta Depth of Grout Seal Q - P Type of Grout I I Irrigation dAppfox. Depth I I Eastern Surface Seal Installed by DTIII or Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material A Depth ~v`' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR%ADDITION i i DESTRUCTION I I (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 L`4 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 D 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 t DISPOSAL PONDS O 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: "I certify that in the performance of the work for which this permit is issued, I shall no\ employ any person i uch or as to beco subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follow' g "I ce i t the pe -.mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of rni .' The appli an st all f r all in ctions. Complete drawing o rse side. � G C- ' Signed Title: Date: x / FOR DEPARTMENT USE ONLY Application Accepted by Date �� Area Pit or Grout Inspection by � � Date / Final Inspection by "'�` Date Additional Comments: / Applicant - Return all copies to: San Joaquin County Public Health Services �1r Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 �FEE FO AMOUNT DUE AMOUNT REMITTED CASH RECEIVEDBBY DATE PERMITNO.if E 13-2t(REV.+ins) /!�� EHH 14-14-20-