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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIn, PROBE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERRIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to Sea Joaquin County for a permit to construct and,/or install the vork herein described. This application is made in cotapliance vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address t�'ir' / ° y/� -_/l�l�� City Lot Size/Acreage Owner's Name Address J2'/" "!' _ Phone 249 Contractor ,, Andress_ �r?�l/ � _License No. & Phone�V:: TYPE OF WELL.IPUMP: NEW WELL C WELL REPLACEMENT n DESTRUCTION D Out of Service Nell PUMP INSTALLATION C7 SYSTEM REPAIR 0 OTHER O Konitoring Wel 0 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 r IndustrW D Open Bottom 11 Manteca Die. of Well Excavation_ _ Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing____ Specifications ('I Public I.1 Other n Delta Depth of Grout Sea! Type of Grout 'OV 1 irrigation _ Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done D Type of Pump H.P- State Work Done_ Well Destruction Q Well Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ! DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feat,i (� Installation will serve: Residence_ Commercial__-_, Other Plumber of living units: Number of bedrooms Character of soil to a depth of 3 teat: Water table depth SEPTIC TANK ❑ Type/Mfg _ Capecity No. Compersrnents PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Y Property Line LEACHING LINE Ll No. A Length of lines Total lengthlaize FILTER EIED n Distance to nearest: Well Founaation _ Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to newest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify,that I have prepared this application and that the work wilt 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 of 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 ust .11 it Ire tions. Compiwe Crawing on reverse side- te�r?�.t� Signed � �Title: +t � - � Date: �11�TMENT USE O Application Accepted by Date Areai�a ` �y r Pit or Grout ktapection by Date Pinel ln■pection b ...- "'�aLe ?_t J (S Additions! Comments: ( grew, 'm 4&—e /)-/..4 Applicant - Return all copies to: San Joaquin County Public H alth Services Environmental Health Permit/Services f/Q 445 N San Joaquin, x 2009, Stkn, CA 9520Y 4 L n FEE INFO AMOUNT DUE AMOUNT RE44ITTED ECEIVED BY D TE PERMIT NOO. . EH13-NrRtV.' Msi ? („ t / t/' —/`; ' EH 1120 Y�