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APPLICATION �!!!2 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f' i,N V I RONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, .CA 95201 I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Arplication is hereby evade to San Joaquin County for a permit to construct and/or install the work herein described. This arplication to evade in coMllance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �� ' �T—_._. ____ City C C Lot Size/Acreage Owner's Name —I`�/ t / Address Com(_/. _ Phone Contractor. L r j� -d rens _ -C C � ��License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION n Out f Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR Ll OTHER monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _._ DISPOSAL FLD. Pbbb�R'''OP. LINE C f C) FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r I Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing f I Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications I"I Public (1 Other 11 Delta Depth of Grout Seal Type of Grout I I Irrillation ___ Approx. Depth I I Eastern Surface Seal Installed by Rnrsir Work Done U Type of Pump H P. _.._� State Work Done _ Wall Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth W TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I INo septic system permitted if 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 SFPTIC TANK ❑ Type/Mfg _ _ _ Capacity_ No. Compartments PKG. TREATMENT PLT. f_l Method of Disposal Distance to nearest: Well .._ Foundation _ Property Line LEACHING LINE L-1 No. 6 Length of lines _ __--_ Total length/size FILTER BED (_I Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS 11 Depth ____ Size __.. .` Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hareby 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 ►tome 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 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 must call for all required inspections. Complete drawing on reverse side. ' Signed X>ti%1( 41- / /�1.L.l Title: Date: [l — - 2 y \ FOR DEPARTMENT USE ONLY � •�% � _ Application Accepted by Date(J — t1 Pit or Grout Inspection by Date Final Inspection by te�`1_ Additional Comments: — '��-? ApplI, ant - Return all copies to: San Jonquin County Public Ifealth SerViCeS Environmental Health Permit/Services 445 N San Joaquin, P O Ron 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO 914 1374 IafV „.si 77 Oo r rr 14 M