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APPLICATION 9 _ffl6 9 SAN JOAQUIN COUNTY PUBLIC HEALT�'R S "4"4'R �•-7 ENVIRONN[ENTAL HEALTH D"V 445 N SAN JOAQUIN, PHONE (2� 34-0-6--r-+-- P O BOX 2009, STOCKTON, yvuf_� PERMIT EXPIREg 1 YEAR FROM DAMElfl SUED (Complete in Triplicat 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 PuLlic Health Services. Job Address 4 }�( �1 A1 � City { Lot Size/Acreage 1� Owner's Name 11Lt� -tiC2 Address Contractor C Address License No, _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 D Industrial ❑ Open Bottom Ci Manteca Die. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack* L) Tracy Type of Casing_ Specifications f'1 Public 1-1 Other i-] Pena Depth of Grout Seal Type of Grout �.�.y I I Irrioation —Approx. Depth i I Eastern, Surface Seal Installed by V` Repair Work Done L3 Type of Pump H.P. __-� Stag Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material t Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITIONDESTRUCTION I I INo sepirc system permitted if public sewer is available within 200 leet.l Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of roil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Cl Method of Disposal Distance to nearest: Well Foundation _ Property Line ,011 A LEACHING LINE A�_No, $ Length of lines _ i oral length/size FILTER BED ❑ Distance to nearest: Well Founaation _ Property Line It SEEPAGE PITS Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 lodowing: "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 shad employ parsons subject to workman's compensa- tion laws of California." The appiica ust all for all r rnspectro Complete drawing on r roe side. / �j Signed �_M �� - Title: �031L""f Date: . `" ~� FOR DEPARTMENT USE ONLY [/f; /�. Application Accepted by Date • Area L' ritdr Grout inspection by Date� �Final inspection by Pate IIIIII L Additions l Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ��f 945 N San Joaquin, P O Box 2009, Stkn, CA 9520 YVC(Q Z r I IN AMOUNT DUE AMOUNT REMITTED CASH RECf BY PATE PERMIT'N0. EM[3.2411tEV.iiKSr / fJ[/ / ! r � �! / _ / 9 / EH r4-2E