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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 , P 0 BOX 2009, 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 conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �f ,y�jy,'� {/Job Address pff 50L flo City R `� Lot Size/Acreage 74F ?-6 1/Owner's Name /�• � J01Address _275 ©/1+�� Phone contractor Address CA01" License Pio. Phone 93- TYPE OF WELL/PUMP: AW WELL ❑ WELL REPLACEMENT l:} DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS M INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing w [I Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public 1.1 Other (1 Delta Depth of Grout Seal Type of Grout I ) Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done w Weil Destruction O Well Diameter Sealing Material & Depth Depth Filler Material E OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i DESTRUCTION N septic system permitted if l,bilE sewer is dable within 200 f�,� Installation e: Residence_ Commercial Oth. Number of living units: Number of bedrooms O Character of soil to a depth of 3 fee . Water table depth SEPTIC TANK ❑ Type/Mfg Ca No. Compartments C PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well oundation Property Line LEACHING LINE Cl No. & Length fol es Total length/size FILTER BED f 1 Dista o nearest: Well Foundation Property Line SEEPAGE PITS II Depth Size Number SUMPS LI Distance to nearest: Well Foundation_ Property Line D15 At PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance s-Itato laws, and rules and regulations of the San Joaquin County Homeowner or licensed agent's signature cenifies 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 t at 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 usT Ii for ail fired i i Complete drawing on r e. Signed Title: 4 _Y Date: 0 DEPARTMENT USE ONLY Application Accepted by DatAJ- e 93 ea Pit or Grout Inspection by / Date Final Inspection by pate 1701;142 Additional Comments: elOt S �1�fC 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 \ INFO O EE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Erni ii. tREV.r M sr s t o r C! rOG a7 S 9 o 3