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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONTMENTAL, HEALTH DIVISION t445 N SAN JOAQUIN, PHONE (209)468-3420 P O BO%2009, STOCKTON, CA 95201 RPERMIT EXPIRES 1 YEAR FROM DATE ISSUED ('Com lete 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 cmwliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �.. Job Address _ r City� at Size/Acreage Owners Name Address � Phone ,36' .?06e i Contractor - i _Address License No ��/ � � TYPE OF WELL/PUMP: ..�Phone NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Li PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESL7 DISPOSAL FLD. PROP. LINE FOUNDATION ___ AGRICULTURE WELL OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRiJCTION SPECIFICATIONS n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Cl Domestic I Private ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing ype of Casing_ Specifications f'l Public 1-1 Other n Delta Depth of Grout Seal I I Irrigation Type of Grout g' ._._..Approx. Depth I I Eastern Surface Seat installed by Repair Work Done Q Type of Pump H P Well Destruction/ ❑ Well Diameter Sealing Material & Depth State Work Done Depth Filler Material S Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION Ir+�DESTAUC710N I 1 tNo septic system permitted if public sewer i a S =� Installation will serve: Re 'd c6 Commercial Other available within 200 feet.) Number of living units: Number of edroom - Character of soil to a depth of 3 feet: SEPTIC TANK- '" ❑ Type/Mfg Water table depth P PKG. TREATMENT PLT. 0Capacity:_._ _ No. Companments 1 4 ..� ^ Method of DisposalDista : eProperty Lineon LEACHING LINE L�—No. & Length of lines FILTER BED Total length/size C] Distance to nearest: Well Foundation �� / Property Line SEEPAGE PITS 14/Depth cS f Sire+ aSLIMPS Number LI Distance to nearest: Well e - ; Foundation '410fr I) DISPOSAL PONDS ❑ Property Liner 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 certifies the following: "I certify that in the performance of the work for which this permit is iss employ any person ued, I shall not 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 Il all required c ons. Complete drawing on reverse side. r - Signed I ! - Title:- . Date: O EPARTMENT USE ONLY Application Accepted byr O or Grout InsDate Area pection by A I I" ate'�L1ZFinal Inspection by Date "� r Additional Comments: Applicant Return all copies,to: San Joaquin County Public Health Services ` Environmental Health"Permit/Services 445 N San Joaquin, P 0 uox 2009, Stkn, CA 95201 '\! FEE AMOUNT DUE AMOUNT REMITTED CK 44�a INFO CASH RECEIVED BY IDI � EH 13-ZI tREV.1rM51 c A� PERMIT NO. -EH 14-20 � 9zZ a