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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH S CES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application In 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 Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f Job Address L --� 75' I—rqCrwq City �� tot Size/Acreage y ae^°� _ /t� ,1�- Owner's Name 0; �d� Address /b ` 00 %4 t e_r Qf Phone u 14 Lo A V*m Contractor �� d�► *1f;? tPAddress License Floe>:7—Sla6IF6 Phone 7Y5-X TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM}EPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Of �r�4..T OSPOSAL FLO. L2 PROP. LINE ?:q' FOUNDATION :VE AGRICULTURE WELL N OTHER WELL/Q PITS/SUMPS INTENDED USE TYPE OF WELL PA08LEM AREA CONSTRUCTION SPECIFICATIONSAJ 0 Industrial 0 Open Bottom G Manteca Oie. of Well Excavation �., Dia. of Well Casing n Domestic/Private ❑ Gravel Pack a Tracy Type of Casing �1' {C -010��J Specifications i 1'1 Public Cl Other 1-1 Delta Depth of Grout Seal 73 Type of Grout I I Irrigation y9Approx. Depth l I Eastern Surface Sedl Installed by Repair Work Done U Type of Pump H.P. State ork,Done— Well Destruction ❑ Well Diameter Sealing Material & Depth 33 //&e..,,&M JV Depth Filler Material i Depth t o? P�✓f' �ir,o�l TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other dumber of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ MethAt� w ft Distance to nearest: Well Foundation Property U RECEIVED LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation PropertyALine N JOTOUTWC-fSUNIY SEEPAGE PITS 11 Depth Size NumbeONMENTAtHEALTH D!r I510N SUMPS L:l 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: "I certify that in the performance of the work for which this permit is issued, I shall nos employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of subcontracting signature certifies the fotlowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applicant must ca or a1 req rpspections. Complete drawing on rpfforse side. Signed X `; Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Data P 113 Area � �fJt � kr 1 G1 Pit or Grout Inspection by Dater J Final Inspection by _.T Date Additional Comments.- Applicant omments:Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 R San Joaquin, P O Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT,NO. EH 1 3-24 IAEV.1/14 5) �� O� z -2—2 EK 14.20 V A i