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r' APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HEALTH DIVISION A Y 445 N SAN JOAQUIN, PHONE (209)468-3420a N 1 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 compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatlons of San Joaquin County Public Health Services. Job Address r 4 El ,(% - led,Y_ _ CityAeT Lot Size/Acreage Owner's Name Sir .,_,.. Address 25j44 N•• E'I+SAzy,-A�, 19 Phone 30'-1909 Contractoruzaptis0,c 11 Qgi l I l!�EAddress -?a t f 64 ;2t% o Phone C } icense hto, TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ x PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES 10 _ DISPOSAL FLD.15 0 PROP. LINE FOUNDATION j00 AGRICULTURE WELL OTHER WELL PITS/SUMPS ,INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial >tOpen Bottom ❑ Manteca Dia. of Well Excavation L1L Dia. of.Welt Casing 1 ,Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_4Ti�/=L _ Specifications---- I'i Public 1-1 Other I1 Delta Depth of Grout Seal t. Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal installed by VCb t, v " Repair Work Done U Type of Pump -5�lhtw �. H.P. lr State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth =� Filler Material & Depth 4 TYPE OF SEPTIC WORK: NEW.'INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public-sewer is ^* available within 200 feet.) Instillation will serve; Residence_ Commercial_ Other f .'Number ofliving units': Number of bedrooms Char6cter of soil-to a depth of 3 feet: Water table depth SEPTIC TANK O Type_/Mfg _ _ Capacity No. Compartments ' P'KG. TREATMENT PLT. ❑ Method of Disposal # Distance to nearest: Well Foundation Property Line LEACHING LINE U. No, 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest; Well Foundation Properly Line , SEEPAGE PITS 11 Depth Size Number SUMPS CI Distance to nearest: Well Foundation Pro � Property Line - -; DISPOSAL PONDS ❑ I hereby certify than 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 a fi 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 signatuWa 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 uat c I r II r quired in ctions. Complete drawing on reverse side. Signed Title: 1512 0 V&Ti,a Date: ` F DEPART E 7 USE ONLY Application Accepted by f Date 4FS0! 2 Area .___ 8 ! Pit or ra Inspection by L " Date _Final Inspection by Date �y2 Additional Comments: _ 1 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services IZV 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 `"Vrb� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. ' INF,A CASH r j� f . Eli 13-24(REV.Inas)EH 14-20 IPA �j.�1C# �e,>t 1-;q j47— ` Gem f ��Y�E�O 41 ��#