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• APPLICATION • ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 468-3420 ZbL� 31,4�, P 0 BOX 2009, STOCKTON, CA 95201 64D4—+n% ' 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 vork herein described. This application is made in camel once vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address < 1 -^� ' �r �?'\c4'1 City *Ct* • Lot Size/Acreage Owner's Name �� Address Chy^..C2�1 Phone ■ eco° L oz� 23�s � � x� O,2. � �License No. Phone 68 C9)4GS �� ■ Contractor Address } TYPE OF WELL/PUMP, NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well PUMP INSTALLATIO SYSTEM R�PAIR ❑ [OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANI. SEWER LINES ^�L DISPOSAL FLO. ' PROP. LINE lD FOUNDATION AGRICULTURE WELL OTHER WELL � PITS/SUMPS�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ti ' )C7;; - 1tiw\�fiali ❑ Open Bortom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casin ❑ Domestic/Private 'ZGiavel Pack ❑ Tracy Type of Casing �"�� 4t% ?,i c- Specification,']� �0 PI Public ❑ Other fl Delta Depth of Grout Seal C - 411s, Type of Grout.'--11.0 :L I I Irrigation CcLApprox. Depth'I 1 I Eastern Surface Seal Installed by J�Rt��PS1 Repair Work Done 0 Type of Pump Nl H.P. \ ` Depth- Work Done Seal l,- Well Destruction ❑ Well Diameter ' Depth �t•D �£ v^ Filler Material i Depth -* Q (.^C- TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADOITION I I DESTRUCTION I I INo septic system permined if public sewer is available within 200 feet.) Installation will sane: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of wil to a depth of 3 feet: Water table depth SEPTIC TANK- ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. i Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ' SUMPS LI Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ I hereby certity 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 Josquin County Home owner or licensed agent's signature certifies the following: "1 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 workmen's compensation laws of California." Contractors hiring or wb-contracting signature certifies thefoll w" g: 'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa• ve tion lame aof C omia." ' The applica must call or r used in ions. Complete drawing on reverse side. Signed / - Title: G7 C �t • Date: d'q FOR DEPARTMENT USE ONLY Application Accepted by r i T— Date `•"� I Area Pit or Grout Inspection by Date ///1 Final Inspection �by(�� [� C Date ' Additional Comments: P55 QellE¢..Ifid..•t.� i7 bX t�ru m^ 1-22'14 �1i &2a f'1�>`LhM e✓\C1LQ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IFEE NFO AMOUNT OUE AMOUNT REMITTED CCR * RECEIVED BY DATE PERMIT'NO. Page 13.- EM 13.24 IReV.i,n•.r fi� lJ c/ 1 0 2 L Tl I I �� 11� 1•ZU" l.T a�2c�