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., APPLICATION v SAN JOAQUIN COUNTY PUBLIC HEALTH SERV =CES �N ENVIRONMENTAL HEALTH DIVISION ] 445 N SAN JOAQUIN, PHONE (209)-468-3420 P 0 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �y� / City .-- Lot Size/Acreage 25C A44!1-7 Job Address [4) 'L MAddres� 5 Phone Owner's Name L' Contractor Address � icense NPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial CJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'! Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR 1ADDITION;X,, DESTFIUCTION,iX INo septic system permitted if public sewer is availabte within 200 feet.I Installation will serve: Residence= Commercial V Other_ 6*44�) Number of living units: - Number of bedrooms_ ic 10 Character of soil to a depth of 3 feet: ' -- _ _Water table depth SEPTIC TANK Type/Mfg ,1_?` f - _.— CapacityNo. Compartments E f PKG. TREATMENT PLT.C1 Method of Disposal Le s ♦ Distance to nearest: Well /Q2 4 Foundation�� Property Line LEACHING LINE 01067`0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS J467�7 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Home owner or licensed agent's signature cenifies the lollowing: "! certify that in the performance of the work for which this permit is issued, I shall net 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 persons subject to workman's compensa- tion laws of California." The applicant.m t I r al requi d inspections. mplete drawing on reverse side. ,f Signed V Title: Date: 401 40" A4FOR DEPARTMENT USE ONLY Application Accepted by Date y� Area /l Pit or Grout Inspection by` Date Final Inspection by Date Additional Comments D ✓ 4_ A � ' )AM Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH x •j/� fit] . EM 19.24 1REV.+i K S1 5 /c/�,,-�t,/ r < D - rte✓ � T/�� - - EN 14.26 f l '