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j APPLICATION i n SAN JOAQU IN COUNTY PUBLIC HEALTH SERV I CES 1 O r ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to;San 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 Public Health Services��.,,``((�� ry[ 6 Lbi/�fA,. City Lot Size/Acreage ' Job Address (�`n a Owner's Name�O" .. Address I + Lo � t" - Phone �V' r 7 .w � � �,, :rye • Contractor' `"Addie""ss's^" "�" 'icnse'No� - 'Phone UMP: NEW WELL ❑ WELL REPLACEMENT ri DESTRUCTIO t of Service Well ❑ TYPE OF WELL/P_ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4 DISPOSAL FLD. PROP. LINE S i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION;SPECtFiCATIDNS C1 Industrial ❑ Open Bottom [3Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ ` Specifications VI Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrif)ation — Approx. Depth I I Eastern Surface Seal Installed by t Repair Work Dane U Type of Pump H,P. State Work-Dane `M Well Destruction � Well Diametef _rSealing Material & Depth_ _ _ ' Depth<r�fl! Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1;•1 REPAIRJADDITION i I DESTRUCTION I :I (No septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence Commercial_ /Other Number of living units: Number of bedrooms r Water table depth Character of soil to a depth of 3 feet: i ! i SEPTIC TANK. ❑ Type/Mfg Capacity. _ f A No.Compartments PKG. TREATMENT PLT. ❑ "" "" Meitiod of Disposal Distance to nearest: ,t N Well Foundation Propeny,Line_-r_, 'I-f-a '• '.+-- - . ��YYY { F ' 1 LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED 0 Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Size Number SUMPS E1 Distance to nearest: Well Foundation -t Property Line DISPOSAL PONDS ❑ I hereby certi at I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and ra tat ns a he an Joaquin Cour t Home owns or h an age 'a sig atur rt' r the Toll Ing:,"I certify that in the performance#t;the work for which this permit is issued, 1 shad not employ any rs n ins ch me ner s t a subject workmen's compensation laws of atifornia." Contractor's hiring or subcontracting signature r certifies the f it Ing: " ertif t in e o ante o e work for whit is permit" sued. I shall employ persons subject to workman's compensa tion laws of ornia." The appli a t f r all r ins o Co Iota drawing on re a e. Signed Title: Date: OR DEPARTMENT USE ONLY Application Accepted by I Arae Date '' Z— Pit or Grout Inspection byDate .Final Inspection by 11 it Date "Z 2 Additional Comments: j - Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services t 445 N San Joaquin, P 0 lox 2009, Stkn, CA 95201 E AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. CK 0 h � CaEH 13.21(REV.six sl f �Q Q. �� {,�D25 "i I Z- EH 14,2a // v I f