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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 i (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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San k Joaquin County Public Health Services. Job Address /209. City!� /V+ _l ! st, Lot Size/Acreage ! /�� /� ''� - f //� y Owner's Name V��/4 15(:4 r" /Address .Iso .V,4_11—A Phone / 72 SQ E Contractor e& Address Con 27 License No. 23 hone TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT .. _ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION,'&', SYSTEM REPAIR ❑ OTHE ❑ Monitoring Well f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Botiom ❑ Manteca Dia. of Well Excavation 7= Dia. of Well Casing fA Domestic/Private IKGravel Pack ❑ Tracy Type of Casing.__J:5,//C Specifications I'1 Public i-1 Other n Delta Depth of Grout Seal lea Type of Grout �O rT I I Irrigation Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump S H.P. M_ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth ; Filler Material 5 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITtON I I DESTRUCTION i I INo septic system permitted if 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 [�Y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of tines Total iength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Welt Foundation Property Line 1 DISPOSAL PONDS ❑ I hereby certify that I 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 nner as to beco a subject to rkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follow' g: "!cert y that in the ante th work for,which thirmit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca'ornia." The applican must call 11 requi in mplete yawing o ev ids. O { Signed Title: '� ell, Date: �D ARTMENT USE: ONLY Application Accepted by Date k b — _k—CLI Area Pit or Grout Inspection by DatelU Final Inspection by Date t F-'"10 Z]. i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �LlJiL�� l'oy2� Environmental Health-Permit/Servicer. 1- 445 N San Joaquin, P O Box 2009, Stkn, CA IFEEO AMOUNT DUE � AMOUNT REMITTED C K RECEIVED BY OATS PERMIT'NO. ! r EH 13-24 IREV.t o SI WR rf 1J I Q/ Z'�S3 Il EH 14.26 ` 5�[ S