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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ANNED 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby rade 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 Public Health Services. 2 Job Address = e _70 City Lot Size/Acreage/_0_0 Owner's Name dress Phone ! �7 Contractor s / ansa No, Q Phone TYPE OF WEL /P ry : NEW WELL 10 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ .� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I 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 Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public f.7 Other t tl Delta Depth of Grout Seal Type of Grout t I I Irrigation —Approx. Depth l I Eastern Surface Saul Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth —— Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION r r, 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 t" Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _ t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well.9 Foundation-7— Property Line 4 LEACHING LINE ❑ No. & Length of lines ._ Total length/size / FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth IF Size= N mbar SUMPS LI 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 parsons subject to workman's compensa- tion laws of California." The applicant must call for all re ed in Pe, io S. Complete dra on reverse side. Signed X--�✓% l f �" itle:�'� Date: r _� FOR ARTMENT USE ONLY Application Accepted by "7 -+rt j Data Area Pir Grout Inspection by ate, / Data �� Final Inspection by'7� Z� � -9 Additional Comments: Applicant - Return all copies to: San Joaquin County Public stealth Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH • EH13.74 Ift-W.I/AS) �) ' l,. --.. EH 14.25 ��, �-� Z j -� �� 93- 21 ii