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APPLICATION � . 'SAN JOAQUIN COUNTY PUBLIC HEALTH' SERVICES r + ENVIRONMENTAL HEALTH DIVISION J445 N SAN JOAQUIN, PHONE (209)468-3420 rp � P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicationis 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 Publics Health Ser' /vi-c1es. x Job Address _l VO !_- N1 W-r L* � l4 41S !;T- City Soh. • Lot Size/Acreage kOwner's Name 4 e Y V.�f. �.• fit 5 Address 1 Yd w' 1 r a"h ,S Phone Contractor OyitAf Address - ___aq&- a .—License No. Phone TYPE OF WELL/PUMP: NEW WELL-0 WELL REPLACEMENT F DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Q Monitoring well DISTANCE'TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ E INTENDED USE TYPE OFFINELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Botiom C7 Manteca Dia. of Well Excavation pia. of Well Casing El Domestic/Private ❑ Gravel Pack- L7 Tracy Type of Casing_ Specifications i'1 Public Ci Other Cl Delta Depth of Grout Seal Type of Grout I I Ifrigation �.Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Materiel & Depth Depth Filler Material B 'Aepth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTEON INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence-A Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK: ❑ Type/Mfg 1_1pift No. Compartments i PKG. TREATMENT PLT..Ll y. Method of Disposal Distance)l�0 n it r"�x,,Epy,I�etion,�. property Line LEACHING LINE ❑ No. & Leig r eE� COm ate �' C�� ( otal length/size FILTER BED C_1 Distance:to rby,covi� tl s,�ak,d� r , Property Line, SEEPAGE PITS 11 Depth ',1 Size ttT€11 — Number--- SUMPS CI Distance':to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s : I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state law"s, and rules and regulations of the San Joaquin County 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 persons subject to workman's compensa- tion laws of California." .. The applicant must call for all required inspections. Complete drawing on reverse side. SignaduJ quo I Title: eAAAA Date:': . 2 3 —92 }- FOR DEPARTNAENfT USE ONLY Application Accepted by 1; ""r'"Date':1"e�`" ,-_;�� Area Pit'or Grout Inspection by Date Pinel Inspection by Data _ Additional Comments: AjPlicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services a 445 N San Joaquin, P 0 B 2009, St", CA 95202 ox �- FEE INFO AMOUNT DUE 3.� AMOUNT REMITTED CASH K A RECEIVED BY DATE PERMIT*NO.� . EH 13.24 IREV. EH t4•Ia