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APPLICATION 'A SAN JOAQUIN COUNTY PUBLIC HEALTHICESOv �� h ENVIRONMENTAL HEALTH DIVIS AW 445 N SAN JOAQUIN, PHONE (209) 20 P O BOX 2009, STOCKTON, CA ccCCJJ�� PERMIT EXPIRES 1 YEAR FROM DAN pp (Complete in Triplicate NV u (e?OO Application is hereby made to Ban Joaquin County for a permit to construct and/:pr application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations cl bau Joaquin County Public Health Services. '2 7-2/ N. Z:5 4 4,0A/ ,14 A0 Job Address .-Mi Al. e1c9A9ZV _ M'f-w ----- City Lt'�L _ ot Size/Acreage A- I r CALvN- BC-610r )eP r Owner's Name r&4409C Address r-,---//!'_y_,Z4Phone Contractor Add resslZMAl-AE51n -1�4 License No.4 Phone ,SZ?7_ 1YO TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I-1 DESTRUCTION 11 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR I I 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 [1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L I Domestic/Private C1 Gravel Pack ❑ Tracy Type of CasingSpecifications I I Public 11 Other I1 Delta Depth of Grout Seal —_ Type of Grout .—� I I Imijauon —_ Approx. Depth 1 I Eastern Surface Sdal Installed by Repair Work Done L] Type of Pump H.P. — State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth __ C•� Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW 1 STALLATION I I REPAIR/ADDITIQN I I OLSTRuCTION I I (No septic system permitted if public sewer is it� . [QLa�iON EST s available thin 200 Inet.) allanon will serve: Reside ce_ Commercial— Other Number of living units: Number of bedrooms f�L� Character of soil to a depth of 3 feet: ___-__. _.____ __.—_ Water table depth _ v SEPTIC TANK O Type/Mfg ___ _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ___ Property Line c� LEACHING LINE 0 No. b Length of lines _ __�._—____--_— Total length/size_ FILTER BED Cl Distance to nearest: Well .—_ Fourroatron Property Line SEEPAGE PITS 11 Depth Sire ___ 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, slid rules and regulations of the San Joaquin County J Home owner Or licensed agent's signature certifies the following: "I cavity that in the performance of the work for which this permit is issued, I shall not t� employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature V certifies the following: "I eenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa cion laws of California." I he applicant t call fo ,&4!equired inspections. Complete drawing rev me side. p Signed Title: � Date: a q 3 FOR DEPARTMENT USE ONLY A Application Accepted by -*/ __ _—___-__ Date Area _ Pit or Grout inspActiorl by Date_ Finel11nspection by ` Datah4W ✓r "�� Additional Comments: �` i rl/ /l1 Applicant - Return all copies to: San Joaquin County Public lualth Services lKu'vl� if s7jb'�/Q►Tr Environmental Health Permit/Services 61AI.*5. r ` 445 N San Joaquin P O Box 2009, SLkn, CA 9520] , FEE y AMOUNT DUE AMOUNT REMITTED r INFO /(///,,,CASH HECEIr1V�EO By / p TE / PERMIT NO. EN EM r7 14 INEv r ih ar �� co r `��`� C( EN 141e