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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 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 work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. p .lob Address M4_ z/�-C�%�/JC[.K 9 City Lot Size/Acreage Owner's Name �,/ 1JA'/F AIQU V6& Address _Ir J� 06� 0OXi9O Phone Contractor Address Q 21 License NO._ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 't DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F.) Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications P` f i'l Public la Other i-1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler-Material & Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:' Residence' Commercial_ Other _Nub of living units: Number of bed Dome Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg _J r2A , �Capacitv._4m No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal l bistance to newest: n^"Well :_ Foundation 4 Property Line' LEACHING LINE 4 ❑ No. & Length of lines — Total— length/size-FILTER BED 1-1 Distance to nearest: Well Foundation Property Line fwd' --I t "tSEEPAGE PITS � Depth —Si,, /y] .OF�� Number - I SUMPS El Distance to nearest:' Well jy�c�� tFoundation Property Line ;DISPOSAL PONDS` ❑ s ' -41 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 r ' ` 4 Home owner or licensed-agent's signature certifies_the.following:4',] 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-is4ssued, l-shall employ-persons subject to workman's'compensa- tion laws of California." r • k The applicant mus call for all required inspection . Complete drawing on reverse side., -Signed Title: -- JlIL�19� _At Date: 4 rFW DEPARTMENT USE ONLY - =1 - � Q� Application Accepted byG.rn -;,._�� Date `-' {ilea ""� r' " a d Pit or Grout Inspection by 0 Data Final inspection by Date f 17 Additional Comments � t - - . Applicant - Re� Health Services 0d , Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn CA 2C INFO FEE AMOUNT DUE AMOUNT REMITTED c CASH RECEIVED BY DATE PERMIT'NO. _ . EH t�14-A-24IREV.1/MSt �l EH s L 2, C?2- 73 F