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APPLICATION -SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 20091 STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a (Complete in Triplicate) Application is hereby made to'Sen 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 Public Health Services. Job Address 14� C7 1 1� W�AA�4 City Lot Size/Acreage01 Owner's Name .`�. Address9�,��\,�Cb.1.A/� Phone ✓ Contractor Address License No. Phone TYPE OF WELL/PUMP% NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [l Domestic/Private ® Gravel Pack ❑ Tracy Type of Casing_ Specifications I.] Public f-1 Other Gl Delta Depth of Grout Seal Type of Grout I 1 Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done IJ Type of Pump H.P. State Work Done l Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms _ T Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg w Capacity No. Compartments PKG. TREATMENT PLT, C1 Method of Disposal Distance to nearest: Well __ Foundation Property Line r" 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 L1 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 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 m st call for all required ' Rections. Complete drawing onrse side. �2— Z/ Signed X a .tom/ _ Title: 00 ✓ �✓ Date:' ,21 a DEPARTMENT USE ONLY —1 Application Accepted by Data 4� Area 1 Pit or Grout Inspection by Date Final Inspection by Date ' Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED By DATE PERMIT N0. + EN 13.24(RE EM 14.2E V.I/K51 LE r op %o p 71-}s� �_ '1_7 �C� L v