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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 00 (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. 549 and 1862 and the Rules and Regulations of San Joaquin County nPuubblic Health Services. Job Address 7` ,ic /J• W115&AJ City Lot Size/Acreage 7Z An- Owner's Name Ate✓ ' ""'�`'�s Address �1�7 7 N•W& zuj / Phone / .7-7620 ContractorL 3&,1r M.A✓�G+�• Address/41 A4 ��- 4A) � License No.C�L� Phone/�"��7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)($ Mo[l4toring Well C3csl6 �'1 DISTANCE TO NEAREST: SEPTIC TANK N A SEWER LINES �� DISPOSAL FLD.� PROP. LINE 2L1 FOUNDATION _TA/ AGRICULTURE WELL N A OTHER WELL N�Q PITS/SUMPSA. . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 6 of Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ q- Specifications I.1 Public Cl Other 171 Delta Depth of Grout Seat Type of Grou 1 `0 I I Irrigation _.Approx. Depth stern Surface Seal Installed by &*- y Repair Work Done U Type of Pump H.P. __ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material b Depth TYPE OF S TIC 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 se Residence, Commercial_- Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Ater table depth SEPTIC TANK O Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well tion Property Line LEACHING LINE Cl No. & Length of lines f length/size FILTER BED ❑ Distance to nearest: ell Foundation y Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Dist to nearest: Well Foundation Property Line 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 Homo 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 Calif rnio." The applicant ca r all requ ed inspecti�ompleerawing on averse side. Signed X Title: 12;� JE��/ Date: �lFORD ARTMENT USE ONLY Application Accepted by 1' 1 Date 4„ �.5J-4 Pit or Grout Inspection by Date Final Inspection by JA A Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services u)iq Environmental Health Permit/Services i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED By GATE PERMIT'NO. EH 13-2tIREV.rinsr St�1r//(, ,OQ J y,/yt 1-2-�2-)y M�EH 71.20 E�(V V O T l/ ,,