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t: APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201. PERMIT E%PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) work in Application is hereby incompliance Joaquin County Counr a ty ordinancenstmet No. 549Bando1862sn dltheeRules andeRegulationsdof Sans application is made in comp Joaquin County Public Health Services. Job Address 16645 SEIDNER RD . _ City SC_ ALT Lot size/Acreage LOUIS MANKILLER Address 16645 SEID-NER RD . ESCAL.Og,one 838-1776 Owner's Name , jiFE.NJ GS_B��-L-Address License No. 0— Phone 545-11 a Contractor —_ WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ TYPE Of WELL/PUMP: NEW WELL C] OTHER C] Monitoring Well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 a D r} SfWER LINES 10�_a t DISPOSAL LLD• Pp PITS/ LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA.4 CONSTRUCTION SPECIFICATIONS rr -�� Dia. of Well Casing Dia. of Well Excavation El Industrial ❑ Open Bottom ❑ Manteca RUC Specifications 16 0 a Type o1 Casing_ -•. K] Domestic/Private EX Gravel Pack ❑ Tracy 1 D O I Type of Grout BEN O N I f E ❑ pelta Depth of Grout Seal {"1 Public1-1_Ot / HERRINGS BROS. I I Irrigation pprox. Depth I I Eastern Surface Seal installed by H P State Work Done— Repair Work Done U Type of Pump 611 -- Sealing Material & Depth S Well Destruction CX Well Diameter �-- r r. Depth 94L " 1 Filler Materiel & Depth TYPE Of: SEPTIC WORK: NEW INSTALLATION l I REPAIRrADDITION ! i DESTRUCTION I i availableseptic wthin 200 feetlstem .jed if public sewer is a � v Installation will serve:' ;Residence' Commercial_..^ Other 1 Number of living units: Number of_bedrooms Water table depth Character of g6if td�s,depih,of 3 feet: No. Compartments {� SEPTIC TANK 0 ' Type/M19 Capacity Method of Disposal 7 PKG. TREATMENT PLT. Cl Property Line L Distance to nearesi:, Well foundation pe y I TTI Total length/size TEACHING LINE 0 No. & Length of lines property Line �'� FILTER BED CJ Distance to nearest: Well Foundation SEEPAGE PITS I I Depth Sire Number 'I 14'i E E Foundation Property.Line n r" SUMPS t I Distance to nearest: Well i. " - ., • V DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin'cdunty 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 j certifies the following: "I certify that in the performance of the work for which this permit is issued, I shatl employ persona subject to workman's compensa- k tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse $1 Signed x itis: Date: FO DEPARTMENT USE ONLY fL Dais Area Q Application Accepted by Date Date Final Inspection by Pito rout I pection b / Additional Comments: Applicant - Return all copies o: San Joaquin County Public Health Services Environmental Health Permit/Services r .�p San o in, )L,O�Box 2009, Sticn, CA 95201 y f615C/AMOUNT DUE AMOUNT REMI ED RECEIVED BY DjF PERMIT NO. w� 9�d° -3 . �� 3 . £H 13.24[REV.I/As) n �� EH 14.26 !✓ N _.