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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /Dr 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. y r Job Address-. City Lot Size/Acreage i Owner's Name^-' " . -3.3 AddressPl -n`�L71 9,l�Z , ,, Phone F© Contractor �^' + Address�2 License N�.G,�� Phonn TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 5 DESTRUCTION 0 Out of Service Well . .❑ PUMP INSTALLATION ❑ SYSTI!M REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FLD. PROP. LINE M_ r_ FOUNDATION--_-. .3.. :-'� .AGRICULTURE.WEIL_ OTHER_WELL_ PITS/SUMPS Q� INTENDED USE TYPE OF WELL PROBLEM AREA CONS ,RUCTION SPECIFICATIONS A\, F Tndustrial ❑ Open Bottom ❑ Manteca Dia. ofi.Well Excavation Dia. of Well Casing t V C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Casing_ Specifications I'i Public Cl Other. n Delta Depth if Grout Seal Type of Grout ' t I Irrigation —.Approx. Depth I I Eastern Surfaci Seal Installed by r Repair Work Done [iY Type of Pump'J2LdL&!- H.P, State Work Done ' Well Destruction ❑ Well Diameter Sealing Hater al & Depth ,M Depth Filler Materi 1 & Depth TYPE-Of-SEPTIC WORK:••--NEW-INSTALWTION+I—REPAIR/ADDIT•ION I- "-DESTRUC-T•IONA 1 INo-septic system-permitted-it public sewer is--,, available within 200 feet.) " Installation will serve: Residence— Commercial_ Other R Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:' a SEPTIC TANK. O Type/Mfg ^-- -- -- _feet: —Water table depth Capacity No. Compartments PKG, TREATMENT PLT. ❑ r j Method of Disposal Distance to nearest: 1 Well Foun atioW- Property Line LEACHING LINE .0. No. & Length of lines =X._.•-- Total length/size FILTER BED ❑ Distance to nearest: Well Four dation Property Line SEEPAGE PITS 11 Depth Size - 1 Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C! 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 V 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 parsons subject to workman's compensa- tion laws of California." The applican ust call for all required inspections. Complete dura/wing 0Arev ase side. Signed X - rttfe: _ "•� ' -} f Date:' S OR MEPARTMENT USE ONLY Application Accepted by 42fDate Area C Pit or Grout Inspection by Date Final Inspection by -Additional Comments: � i 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. AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT tVO. , INFO � GASH EH 13.21 iREV.1/$5) /�/r+ _r-d i