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APPLICATION FOR PERMIT *"R SAN JOAQUIN COUNTY PUBLIC HEALT ES ENVIRON1dENTAL HEALTH DIVI 445 N SAN JOAQUIN, PHONE (2 9) 6 — 40 +^ Y P O BOX 2009, STOCKTON, CA ER PS T EXPIRE 1 YEAR FR U D T (Complete in Triplicate I Application is hereby made �.to Ban Joaquin County for a permit to construct �nd/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549.and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. I /� i Job Address % Y' h City .TC,c. 6A. i Got Size/Acreage. Z6.00Ow7 y F I . Owner's Namec"U", ICS& A�rILcc1c [n.Addressa110 QCI W 1,ti 6.C�µ�v_t� a,��, RZaAw+1Phone � _9 I� f ]� 'J Contractor ds o s � eAddress Q o icense NoGS7S�.7(9'L Ph one ; 77s TYPE OF WELL/PUMP: NEW WELL F- WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 66 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS ri ❑ Industrial D Open Bottom CI Manteca Dia. of Well Excavatio. Dia. of Well Caping _ KDomestic/Private D Gravel Pack7 ❑ Tracy Type of Casing v EX,N0Re—s— Specifications cp s � f'1 Public El Other [t Delta Depth of Grout Seal O— 2 3 Type of Grout I I Irrigation _.Approx, Depth I I Eastern Surface Soul Installed by S5 ups Repair Work Done 0 Type of Pump H.P. I�State Work Done�l Well Destruction ❑ Well Diameter Sealing Material Depth 4 �' tr ries Depth Filler Material i Depth Ii TYPE OF SEPTIC WORK: NEW INSTALLATION I I 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 ® P Character of soil to a depth of 3 feet: "17ah 1 SEPTIC TANK. ❑ Type/Mfg Capacity n'ients PKG. TREATMENT PLT. ❑ ApRttl o sal Distance to nearest: Well Foundation r Li Q �� `�1 LEACHING LINE ❑ No. b Length of linea otaNi�zeT�F�� FILTER BED O Distance to nearest: Well Foundation Property LIrib t r' 017 SEEPAGE PITS 11 Depth Size Number' SUMPS Ll 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 nature certifies the following: .1 age sig g: "I certify that in the performance of the work for which this permit is issued, I shall net 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 must call for allr ad inspections. Complete drawing on reverse side. j� / -y— Signed Title: j [r�,Tl;�S�e_>__T_f„ _� Date: I � FOR DEPARTMENT USE ONLY f Application Accepted by Date ' [ L/ Area `� (D/ Pit or Grout Inspection by Date Final Inspectio 1by " Date Additional Comments: i i Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Realth.Permit/Services I' 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE ' DKI '' Pare INFO AMOUNT DUEAMOGUNt REMITTED GASH RECEIVED BY /��7PATE PERMIT N0. • EM 13-24 EM li•2a I11EV.yin Sf J1 Z,31 15 Ott) !�[.� .� Z9 LL __ !1