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2:3o APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 73-is c,L P O BOX 2009111 STOCKTON, CA 95201 /60.4--.7 PERMIT EXPIRES x YEAR FROM DATE ISSUED /3y-JVI-7 � ve &J-V4__ (Complete in Triplicate) Application is hereby made,to San To9quin County for a permit to construct and/or inetall the work herein described. This application is made in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f A Job Address ,r •�E�r� �Jt�J h�.vY1 ♦��1"1 �� 1Q- City 1"0- Lot Size/Acreage r� 4tf �. cc�� zi ` sol, Owner's Name Address +f�I"a1�'iht�l'hone Contractor f;✓ - ddresslinlILicense No.� + Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well €� DISTANCE TO NEAREST; SEPTIC TANK A&A SEWER LINES DISPOSAL FLD. PROP. LINA_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIqVS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav 'on Dia. of Weil Casin Domestic/Private Gravel Pack Tracy Type of Casing_ Specifications - 62 I1 Public ID Other C1 Delta Depth of Grout SealType of Grout �u��etarJ+Q I I Irrigation ,Approx. Depth l I Eastern Surface Seal Installed by pfiLUtf^,, Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth O Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to s depth of 3 feet: Water table depth S SEPTIC TANK ❑ Type/Mfg Capacity---- No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 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 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 II for requir in Ctions. Complete drawing on 7rse slide.. rYSigned X Title: 3.�/j _ Date: Je�J C✓� L jo R DEPARTMENT USE ONLY 7-1b Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _fDG _ 106` 1.,3. !�L,4 _`ApP cant - Return all c fes to; San JoServices 7/t02- aquin County Public Health �*�� arm f h �OYo� 1.) a=/Sd f Environmental Health Permit/Services Q /V6 { x, C t et-S ra/,, lo2tetJ 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 Q�S111 f FEE V Aa lfQgj a.�.Gl �I/N�F�Oy) AMOUNT DUE AMOUNT9REMITTED CASH RECEIVED BY DATE PE MI7'N0. G�r(�� . EH1 724(REV.Iinsi 4.26 EH 1