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APPLICATION ti SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)468-3420 1.1141 - P O BOX 2009, STOCKTON, CA 95201 FEB 1 81 �l 99; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �N (Complete in Triplicate) p 41 NT,q� ERivllt Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein desr6scribI d. 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 Servi ea. 35 7 �1 < Job Address f Opt City Lot Size/AcrA eage r v t �{ // f n yel .y. Owner's Name ��'^m`U`� �� r Address 3� ��=u'fr1 Pr.J e6-11/ t IE'-[r) C'7 Phone y�y' �SE�' l`l G 7 Contractor 6reSA d d r e s 4 50 14CV,)e Ma.ifine'e C4 License No. I St�16 Phone Sl6`3!3i.3-7-RIC TYPE OF WELL/P P: EW WELL O WELL REPLACEMENT CI DESTRUCTION Ll Out of Service Well D PUMP INSTALLATION a SYSTEM REPAIR ❑ OTHER XC`rMonito ing Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (ear K� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing____ Specifications I') Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Sedl Installed by Repair Work Done U Type of Pump H.P. _._ State Work Done _ Well Destruction O Well Diameter Sealing Material 3 Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I ) REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance 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 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 applican ust call a tuns. Complete drawing on reverse side Signed X _ Title: �� /% �/IIIIDate: FOR DEPARTMENT USE ONLY Application Accepted by Date y Area ov" Pit or Grout Inspection by�/ � Date Final Inspection by Date Additional Comments: -Axje� 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 95201 FEE INFO AMOUNT ]7DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. Page 13A EH 14-26(REV.I/n 51 C, 9 L� lk �d 9� .D EH 14-26 (/x-12 G