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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 20093. 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7505 // 4-f-/2,ia z /ifs City. }l,n Lot Size/Acreage Owner's Name 1'2u A-Ao-L A C Il a m ct Address 4"W L2 Phone Contractor C /lLk , -Ta6ddress 2024 F. Chnnfan U-ajL License No.3-79J6-0—Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENTfkbCX DESTRUCTIOVA9cQvt of Service Well O PUMP INSTALLATIONXQ SYSTEM REPAIR ❑ OTHER O Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK f ,�>.(� SEWER LINES DISPOSAL FLD., � 5(JL PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Ll Industrial Open Bottom ❑ Manteca Dia. of Well Excavation �Z R y Dia. of Well Casing 6 8n [�l)Domestic/Private O Gravel Pack7 ❑ Tracy Type of Casing _ Specifications - I"1 Public Cl Other f 1 Delta Depth of Grout Seal � �! Type of Grouter _ I I Irrigation Approx., Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. t- State Work Done_ Well Destruction O Well Diametera Sealing Material i Depth Depth Filler Material i Depth J 012 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Comm 1-- er, Number of living units: Number of bed Character of soil to a depth of 3 feet: iiiii ri I LF."API ' ED Water table depth SEPTIC TANK O Type/Mfg Permit may t No. Compartments PKG. TREATMENT PLT. O i�rrkk h �r }� �jq �! Method of Disposal Distance to nearest: WWAH b�l� li � ►t' i Ue opperty Line by LEACHING LINE O No. & Length of lines 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 ❑ 1 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 Homeowner 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: "Ithat)p the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Californla ' The applica t f r r uir �"p . Complete drawing on reverse side. Signed Title: I/P C Q U 4 ds !•Lg e e, LQ e Date: 2 4 No)) 92 OR DEPARTMENT USE ONLY Application Accepted by [G`--r ,A,�,-A �,�� Date t 1^�4^ 9�- Area Pit or ro Inspection by Date �� 1� Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95201 IFEE AMOUNT DUE AMOUNT REMITTED I fCK'--1RECEIVED BY ATE PERMIT'NO. • EM 1J•24(REV. /n 5 �t� EM 11.2! � O