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1 _ APPLICATION RANEY rA,z.0-1 rL.0 N e_AL.. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES AT04 : Toxv 5AL1;sER2_, ENVIRONMENTAL HEALTH DIVISION -2,176 I N O V S-rA IAS. &W 445 N SAN JOAQUIN, PHONE (209)468-3420 W f-ST SAc r"�r•Ras G A P O BOX 2009, STOCKTON, CA 95201 x-691 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0110) o43y �� ` � � ��G ot�nComplete in Triplicate) Applicat l n 1s hereby made•to S J qui. C ty 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 1� hzL ?ct_n,;4 tt- A'PN 1-D-1140 ~ 13 City .5T%iueTCUt•1 Lot Size/Acreage 15 ALRL5 Owner's Name ��AS51d2- .It t) CG, Address �3?Z e,trB!t)£ i:T. .5u�Ti'Z __��Z� Phone 3b4� ( AA's t. f.t ZZs Lj_ �U sE Contractor (— itJC . Address 17140401t G,40 YAo LA 22L12- License No.S L!lig Phona) TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ( ii DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK "IA SEWER LINES /� i PT. DISPOSAL FLD. ti PROP. LINE ti, FOUNDATION Grp' AGRICULTURE WELL � OTHER WELL M%A Pg§lSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11, L n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingr�r7�� Ycifications I'] Public Cea tl Other n Delta Depth of Grout Sqype of Grout I 1 Irrigation _Approx. Depth I I Eastern Surface Sedi Installed by Repair Work Done U Type of Pump H.P. State Work Don Well Destruction ❑ Well Diameter Sealing Material & Depth 1J (3 Depth Filler Material & Depth a ;, ;� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) 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 SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line to SEEPAGE PITS 11 Depth Size Number `fes SUMPS LI Distance to nearest: Well Foundation Property Line {, DISPOSAL PONDS ❑ I hereby Certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a 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: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion taws of California." The applicant must call for all required inspections. Complete drawing on rreev.,errssee side. Signed X , Title: -=5 Date: O EPARTMENT USE 0 Application Accepted by Date Area C Pit or Grout Inspection by Date Final Inspection by ,- Date v Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 Sfi RECEIVED BY DATE PERMIT'N0. . EMty24 tnEv', s, ` EH t..m � '