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APPL1CAl'1UN SAA�OAQUIN COUNTY PUBLIC HEALTHRERVICES 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 A)c51-r (Complete in Triplicate) L4 -Hyl e�i-add�ess r. rdpuadT/SoEL ljo.+i43s Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in cowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. • Z's M;SI /I-9 M hjul1iiiynekydrutOIA c n JobAddrass H•��nNfLf)cty ©,.3fn,Ie5Jo.l4�. af/'err-i4„y �pA�eC[f Lot Slxe/Acreage PG+i;6nsS4 p pb S"Je Owner's Name Y QU s i nessL!n I� Address ,7� � � � 1 Phone Te-5 Mar ine-zq'1 yon' Contract BL Addr€Ss 50 License No,�n51�05 Phone TYPE OF WEbLiANMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ 6t pj Ncys PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4• ppP;115;gTHERX Monitoring Well ❑ DISTANCE TO N�AREST: SEPTIC TANK SEWER LINES DISPOSAL FLD..JJ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE Iw/JQ'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ONS o ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Pudic 1-1 Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dona _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Piller Material A Depth TYPE OF SE TIC_WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer p I/,1 available within 200 faet.l Installation a serve: Residence _ Commercial_ Other Number of nits: _ Number of bedrooms Character of soil to a Ih of 3 fmat Water table depth SEPTIC TANK ❑ /Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nears ell Foundation Pmpeny Line LEACHING LINE ❑ No. ngtIt of lines Total length/size FILTER BED �11J�- C3Istance to nearest. Well Fou n Property Line SEEPAGE PIT I I Depth Sire Nu SUMPS LI Distance to nearest Well Foundation Pro Lina DISPOSAL PONDS ❑ I hereby certify that 1 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 cenifies the following: "I certify that in the performance of the wort for which this permit is issued. I shad 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 conpenss tion laws of California." The applicant tell for aR r re/J " sped s. C p/l¢ta drawing on reverse side. 7 �y Signed X Qin/ R.-P/ f 10 . Title: e.6 i ✓.j'.f �j e6I DQ(S't Date: t-' - % 7 �� TFOR DEPARTMENTJ USE ONLY `V Application Accepted by �Y�L°`�� U ` �� 1_A.JrC]6C, Date �^ � � Area PN or Grout Inspection by Date .{Final Inspection by Date Additional Comments: �- If Applicant - Return all copies to: San Joaquin County Public Health Services f2Environmental Health Permit/Services O/ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO FEEAMOUNT DUE AMOU�`NT REMITTED CASH RECEIVED BY DATE PERMI/T No,, pa oe I�A EM 1374 IAEV,I/ser - ©V V IJ— mar' O-- [3— 1 fM