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r APPLICATION SCANNED i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 1 P O: BO% 2009; STOCKTON, CA 95201 PERMITI MIRES 1 YEAR FROM DATE ISSUED 1l (Complete in Triplicate) 4 A"kieaf,llon to hereby made,to I Joaquin County for a permit to construct and/or install the work herein described. This application is etude in eemolianao vami Aan Idoaeltil" CCYirrby bfdin.noo Na. 549 and 1960 and the Ikuais sed Postulations of man Joaquin County Public'29fH�}ealth ServiceA "e' I �/Job Address v .r + City �} Lot Size/Acreage Owner's Name _+�V L1• D ��-f ltAddress � �V � /�� Phone Con �I//l�� Addre3 O� okI Z 2 ) LicenseYNo Z.3/ phone7�� TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT DESTRUCTIONX Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM AEPAIA ❑ OTHER ❑ Monitoring Well C7 DISTANCE To NEAREST. SEPTIC TANK 0V e--1W y SEWER LINES ,L._.d_-_- DISPOSAL PLO. PAA. LINE 4:�do FOUNDATION l� AGRICULTURe WELL OTHLOA WELL.Zd—: --- PITS/SUMPS Za--J "y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTAUCTION SPECIFICATIONS �r Ci Industrial ❑ Open Bottom ❑;Manteca Dia. of Well Excavation Die. of Well Casing fil•,Domestic/Private &Gravel Pack ❑CTracy Type of Casing- e!!e-- Specifications I'l Public l-1 Other n,Delta Depth of Grout Seal d0 — Type of Grout_Af,r ilO-Lt I I Irrigation / Approx. Depth l I i0astern Sudie4P Seel Installed by C-Al Repair Work Done U Type of Pump r H.P. - Statd Work Done Well Destruction _ Well Diameter z , II Sealing PAterlal to Depth Depth— lI Piller MateriAl S Depth TY WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sews ' It avalilable within 200 feet.) i Inaleflstiiin iitiifi wive:' Resideh►i_ Commercis _ it -Q Number o1 living units: Number of bedrooms Q Character of toll to A depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg iI acity No. Cornpartments PKG, TREATMENT PLT. ❑ l �of Distance to nearest: I Foundation Prope !I LEACHING LINE Ct No. & gth of lines i1-- Total Iangth/946 r FILTER BED ,stance to nebre§t: Weil . ; Foundation -- -�� - Proporty Lind a ' SEEPAGE P I I Depth iM Sile Numb6r SUMP Lt Distance to nearest: Well Foundation Property Line `r D OSALPONDS ❑ I hereby certify that I have prepared this application rind 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 lic agent's signature certifies the following: "I carlify that In the performance of the work for which this permit is issued, I shall not ampfoy any can In ns nner as to become I t to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies t #ollowing:"I c i}y the rn th arfo an I of the work for whish this permit is isauad, I shelf employ personas subject to workman's compensa- tion la of Califor a." I The ep licant ell r all r ulrCam Isle dr �V6 side. Signed Tltlei Date: [� MENT USE ONLY 1 Application Accepted by Date - 6, Area o 'S Pit orout spactlon by CI Date FInal Inspection by t. Dates- / if Additional Comments: ' / i Applicant - Rekur all copies to: Sall Joaquin County public tI lth Service Environmental Health Permit/Serbicet3 11-114f<, 445 N San Jokquin; P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT'NO. W r • EH137iIREY.r/nst �" I �� 11 16,440-7 �EH t42e n 92 a�� �� 9a PR