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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 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin Ciiniity for'"4, Permit to oonatruct.`end�or'.install the-work herein described. This application is made in compliance with,San Joaquin Connti Ordinance No. 549 and'1862 and the Rules and Regulations of San Joaquin County Public Health Services. .,/ Job Address Q S• �uf'�h` ,`� r�p City /3 WON Lot Size/Acreage �Z Owner's Name `,cQ�� G fd� J �''Tf Address �r�D j� - _f��w 0- Phone s� 3d'J 3 Contractor �V AddressP6 &L ��fise No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION,X SYSTEM REPAIR O OTHER O Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK 175s SEWER LINES I50' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL0_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing I') Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications I'1 Public EI Other I-1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump onwi".P. /,o �w State Work Done_ Well Destruction O Well Diameter to Sealing Material & Depth (� Depth ;2/41 r Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms DAXEN Character of soil to a depth of 3 feet: Water G,�!'If SEPTIC TANK ❑ Type/Mfg Capacity No. CAV PKG. TREATMENT PLT.❑ Math"Wi"l1 999 Distance to nearest: Well Foundation Property Line SAN JOAQUINOUNTY 4 LEACHING LINE O No. & Length of lines Total leng { FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number - SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 m cal or rrraall r uired i pec ns. Complete drawing on reverse side. Signed G Title: S e CLI ZG P r 2 " Date: OR A USE ONLY Application Accepted by Data Pit or Grout Inspection by Date Final Inspection by Date S Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin ox 2009, Stkn, CA 95201 IEEE MOUNT DUE AMOUlNTT REMITTED CK R CEIVED By y� D TE PERMIT'NO. . EH 13-24(REV.I/n 5) i a ../ EH 14.20 3