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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,.. ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P. 0 BOX 2009, STOCKTON, CA 9520-1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 1$62 and the Rules and Regulations of San Joaquin County Public HeaZ0 , Services. r J� Job Address �Z f�D�Y31 City Y�O Lot Size/Acreage l i Y7Cy�� Owner's Name Y�`�eLl WYr' '5D %CYAMeVd© �' Phone� 33�Ol. Contractor AddressLicense No. Phone — # TYPE Of WELL/PUMP: NEW WELL ❑ .- WELL REPLACEMENT f"1 . DESTRUCTION D Out of Service Well-D f PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION s AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (� (l Domestic/Private Cl Gravel Pack n Tracy hType of Casing_ Specifications i'I Public I:1.Other I-1 Delta Depth of-Grout Seal Type of Grout I I Irrigation �.Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done 0 :Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter S a Depth F _RTanthf h •, TYPE OF SEPTIC WORK: _NEW INSTALLATION REPAIfilApDITION I OF-5 I IN p permitted if public sewer is ,� Permit may have expireda'wi ou{n zoo feet.► .: Installation will serve: Residence � Commercial_ -Other Number of living units: �+* Number of bedrooms N � offing completed or inspected Character of soil to a depth of 3 feet: ealth •,1NIa {fdble depth SEPTIC TANK © Type/Mfg 'Capacity o. ompartrnenta PKG. TREATMENT PLT. ❑ Method of Disposal Distance to near st: Well _ Foundation Property Line L; 75aAXCAI+v� LEACHING LINE Cl No. & Length of lines Total length/size I FILTER BED n Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS I I Depth Size Number SUMPS LI 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 iaws, 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- 43 tion laws of California." The applicant st call for all required inspections. Complete drawing on re se side. Signed X Title: pate; i _,Za f�t 3 11 FOR DEPARTMENT USE ONLY Application Accepted by Date 21 Area Z Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: Applicant - Return all copies .tot San 'Joaquin County Public Health Services r Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201. FEE INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED.BY DATE AERMiT NO. . EH 13-24 MEV.II.., 1 �j �� D/ -• �f EH 1t-2e f