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APPLICATION SAN PAQUIN COUNTY PUBLIC HEALTH •SERVICES ENVIRONMENTAL HEALTH DIVISION � p� � 468-3420 3L)4E l ). n 3,Ld F4 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �5 �- (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. 569 and 1862 and the Rules and Regulations of San Joaquin County �Public Health Services. Job Address (_.`!/C�` X� �` �;Z.�('�,'� .� \_ �� Q CitV�� GLot �Size/Acreage (.�[) Owner's Name? � l `h�`r\`1`^ Address l)�� -e -a bd<'a � n � Phone Contractor_ C'Ll�",v'"� 1- �ICNOc C`�Address L. t ",�.y'2. �1 cK '✓\ o�� (j 5 License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well PUMP INSTALLATITM&I SYSTEM RFCPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. `� PROP. LINE lOt. FOUNDATION _�� AGRICULTURE WELL / OTHER WELL PITS/SU MPS ' �1 r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Yom" 1>�on�i"eR. ❑ Opan Bottom ❑ Manteca Dia. of Well Excavat`io�n-- " Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing-V� �Fy VL 1 Specifications— X00, f'I Public Cl Other fl Delta Depth of Grout Seal c, - Lf-S Type of Grout 14,2Z cs?n I I Irrigation (2L Approx. Depth , lIEastern urface Seal Installed Repair Work Done U Type of Pump H,P. __ State Work Done_ Well Destruction ❑ Well Diameter\ Sealing Material i Depth—X,��'Z CW<�� f1 - 5` Depth - Filler Material i Depthr TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Meth9 od of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size SUMPS Number LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Lina I hereby cenify 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 workmen's compensation laws of California." Contractors hiring or subcontracting signature certifies the loll'w" g ws ; "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 laof C ornia." The applica must call 177d ins pe ions. Complete drawing on reverse side. Signed X /- Title: cJ C ?(LL S, /C� Date: FOR DEPARTMENT USE ONLY � Application Accepted bL Date ` JL,y' [/��15 ' t/ Area Pit or Grout Inspection by of Date 1 Final Inspection by C Data m Additional Coments: y Qgf12q nL,o,`f $l9,(kQt.�Otn �a ��- hh'i ell l/ _ 11LX 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 I r_Jb FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED Sy DATE PERMIT NO. �Is.2zIREv.�,,, g� 0 2� Y� 'fZS`(� o1232a Page 13A