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�a APPLICATION :.;SAN- JOAQUIN COUNTY PUBLIC HEALTH SERVICES FFA445 ENVIRONMENTAL HEALTH DIVISION Z 1992N SAN JOAQUIN, PHONE (209)468-3420 �'S f�yi-' L pv. P O BOX 2009, STOCKTON, CA 95201 �.FER61iIT_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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services Job Address 147 I CityZC&__ r �LotSize/Acreage Owner's Name Cla U i"917 Address SQ ZYP GO P_- Phone Contractor Ldel-01'///77q Address L4—, Id ISOX SPA2 X/4icense No.Y834623 PhoneQ_Q3-_,!�X& TYPE OF WELL/PUMP: NEW WELL O WELL REPLACIMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION dr- SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1] Domestic/Private Cl Gravel Pack ❑ Tracy Type of-Casing-_ _ Specifications I') Public Ll Other n Delta Depth of Grout Seal Type of Grout I i Irrigation ) /e!!Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done C1 Type of Pump H.P. �' State ork Done Sealing Material k Depth r Weil Destruction O Well Diameter _ 15C� CRSS-Yr� Depth Filler Material 8 Depth W t5 G 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No 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 SEPTIC TANK O Type/Mfg Capacity No. ACompartments PKG. TREATMENT PET. D Pa!s4Y�lisaEoq of Disposal Distance to nearest: Well FoundationOrbeB LEACHING LINE ❑ No. & Length of lines T LI 4g Ize FILTER BED ❑ Distance to nearest: Well Foundation �0AW� , T SALTSE!.�` SEEPAGE PITS 11 Depth Size rN111R[ QA��AL SUMPS LI Distance to nearest:• Well Foundation Property Line 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 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 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 ¢ call f r all raqui d insp tions. Complete drawing on reverse side. Signed X Y Title: yoc, Data: DEPARTMENT USE ONtY Application Accepted by Date_.;2-7-f Z__ rea- Pit or Grout Inspection by Date Final Inspection. Additional Comments: 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 FEE INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT'NO. . EH 24 1pEY.„x 5r �' �A 3 EH 1,14.21f