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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BCFX 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. 7 ,c Job Address ,Z 4 0 CZZ4,;� �� '� Cityd� ems'` 3"* Lot Size/Acreage g.F Owner's Name -4-4r\-e— • Address Ji' 1 J 'vV P°� � 1�� i_' APDL; Phone Ct•„ C, .3-3 1) VJ r(Lu� Contractor �. `' U �1.,sy Address � n 6,1--C,$ /'' • �V ✓L� r'-+' License No. � y 7Y � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION Ll out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ti DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE C] Industrial C.1 Domestic/ Private I'1 Public I I Irrigation, "/--� Repair Work Done ❑ Well Destruction O TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CKIll CASH O Open Bottom O Manteca Dia. of Well Excavation IC'- Dia. of Well Casing 4 ` IN Gravel Pack ❑ Tracy Type of Casing Grp' P i/(: � Specifications f 1-1 Other fl Delta Depth of Grout Seal C Type of Grout c-'r0l 3,LY%- Approx. Depth I I Eastern Surface Seal Installed by Lf ' 17f V Type of Pump / f H. P. State Work Done _ Well Diameter ZI Sealing Material & Depth r��l Depth IL Filler Materiel b Depth r TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTR Installation will serve: Residence _ Commercial _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK 0 Type/Mfg PKG. TREATMENT PLT. ❑ Other Capacity Distance to nearest: Well Foundation LEACHING LINE 0 No. & Length of lines FILTER BED ❑ Distance to nearest. I I INo septic system permitted if public sewer is available within 200 feet.) Water table depth _ No. Compartments Method of Disposal Total Well Foundation .•Rmper! I n�nn SEEPAGE PITS I I Depth Size P �� yr+4tv �� SUMPS LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ I hereby certify that 1 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 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 cartify 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. Signed X� !� ` �uhrt z " Title: u°"tt�—'r't/'�.-�' Date: 3 Application Accepted by Pit or Grout Inspection by Additional Comments: FOR DEPARTMENT USE ONLY Data �, to Z� Final Inspection by Area 6 Date Applicant - Return all copies to: San Joaquin County Public Health Services ` �V U� Environmental Health Permit/Services J lJ 445 N San Joaquin, P 0 Box 2009, Stkn, 95201 . EH 13-24IREV.I/M5r EH 11.20 FEE INFO AMOUNT DUE AMOUNT REMITTED CKIll CASH RECEIVED BY OATS PERMIT'NO. �d 3 /o -2,7-73 00/380 O