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�v --------- -7/31 APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I 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. Job Address ' 000 le City L.&C,J`� Lot Size/Acreage ,�) S ,!?� r� �5�V00 WA Owner's Name i d1l] .Address ��4�i �!]Jtn�L-1rii�f`t`.—�_ Pha ^^�� 4em CA e-s7 09 y6�~X71 Conttacto ddresa� �� License No. s1U6I Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP iNSTALLATI NN ❑ SYSTEM REPAIR 01 HER &�— Mo tori Wel DISTANCE TO NEAREST: SEPTIC TANK __v_SSEWER LINES 2�0-�#— D SPOSAL LD. NA PROP. LINE FOUNDATION Z52—'Pr— AGRICULTURE WELT 44q OTHER WELLM= PITS/SUMPS LA- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industria{ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �n Ca Domestic/Private "ravel Pack 0 Tracy Type of Casing_ 5c 0 Specifications � ("1 Public J� Cl 0 her n Delta Depth of Grout Seal Type of Grout�/ ` e I I Irrigation `T�s��pprox, Depth I I Eastern Surface Seal Installed by re, Repair Work Done 0 Type of Pump H.v� H.P. Stat Work one — We/ll Destruction ❑ Well Diameter yIA Sealing Material & Depth t S fp3, Depth O Filler Material & Depth C -0 Q-p} TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system rmitled if public sewer is_ available within 200 test.) installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth p SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Proprp>YA' ��ii°gg''''11��11 � w LEACHING LINE C1 No, & Length of lines Totat lengthlr� FILTER BED ❑ Distance to nearest: Well Foundation Pror SEEPAGE PITS 11 Depth Sue Numb ��' J SUMPS Ll Distance to nearest: Well Foundation (t rLMnlyLfp� r�[� It n_ii�' �)I1'i�le�f1 ,.rv.L'J 1V 1 Y 1.i :'1� -R. DISPOSAL PONDS ❑ �41JJ 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 must call for all required inspections. Complete drawing on reverse side. r- q+ Signed X !<, itle: � SSiS [1� TnTpd �liM�l'Date: DEPARTMENT USE ONLY Application Accepted by .Date 3 3 Pit or Grout Inspection by Date Final Inspection by Date f� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY ,/DATE PERMIT.No. . EH14-24{REV.1/85) ®� O!% SIG SC 7 9� v�,�Z776 EH i4.2a (/ / i `