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APPLICATION SAN JOAQUIN COUNTY POHLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E$PIRES 1 YEAR FROM DATE W,1 (Complete in Triplicate)Application is hereby made to San Joaquin County for a permit to construct and/or insrk herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 5355 N. So-Cal .i Rarzch Ranch4/ON 087-182--39 Job Address City `S-2`kh Lot Size/Acreage 1 112 .4c2P_,S Owner's Name btnie Sm.i.t h Address 424 Q as 4 v e Phone 477-3054 Contractor Clcx2k Mg-Le Address 2024 E. ChaA: tpn Vag License No.371560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELL Z WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service well ❑ PUMP INSTALLATION-I_i SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK __J 1 �,' SEWER LINES DISPOSAL FLD. z 7 Ffl'PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL r ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation._ 21, "T Dia. of Well Casing 9t Domestic/Private vQ Gravel Pack Ll Tracy Type of Casing S�1�Q - Dia.Speof Well Casing I') Public Cl Other Cl Delta Depth of Grout Seal _ 1 C3C ' q0 A'-V n .. hype of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by_C_6a 4.4; _ Repair Work Done 0 Type of Pump __S„0 H.P. State Work Done_ LP Well Destruction O Well Diameter Sealing Material & Depth ` Depth Filler Material & Depth U i TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted it public sewer is ^ Installation will serve: Residence— Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation_ Property Line I� DISPOSAL PONDS p �J J„ 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 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ tion laws of California." P Y Persons subject to workman's compensa The applica cal or 11 ui d pe t s. C late drawing on reverse side. Signed Title: Dare: .RTj 9,'�, FOR DEPARTMENT USE ONLY c� q Application Accepted by Date a- l Z Area Pito Grou Inspection by Date _0 f6'Final Inspection by z Date Additional Comments: 6 C L U�L Applicant - Return all copies to: San Joaquin County public Health Services Environmental Health Permit/Services A 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 �tl �Jti FEE AMOUNT DUE AMOUNT REMITTED CK 0 `INFO CASH RECEIVED BY DATE PERMIT'NO. ♦ EH13.7<IttEV,!/M51 w� ka U �f�� 10—b- EH 14-ai Q J �[a