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I APPLICATION. I I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ' I j" PERMIT EXPIRES 1- YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby rands to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in camilliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San F Joaquin County Public Health Services. ' D Lot Size/Acreage " Job Address City 11 se , Address -� Phone Owner's Name �l=2 Contractor ads w4��Address .& License No.�_Phone s 2 CS TYPE OF WELL/PUMP: --NEW WELL. WELL REPLACEMENT I I DESTRUCTION Cl Out of service Well ❑ ` PUMP INSTALLATION OC SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SE50 PROP, LIN PTIC TANK f 292 SEWER LINES f DISPOSAL FLD.7E fFOUNDATION L�-4? AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-1 Industrial �1(Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Domestic)Private ❑}Gravel Pack7 ❑ Tracy Type of Casing_ STt-7EL-- _— Specifications 1 - i'l Public [1'lOther FI-Delta Depth of Grout Seal l Type off Grout u A rox. Depth I I Eastern Surface Seal Installed by 1 (!�,$ W5/1 `/� 1 i III 11 Irrigation pp L Repair Work Done L7 T'i of Pump _.[!X142 H.P. State Work Done Sealing Material & Depth 4 Well Destruction ❑ Well Diameter �- f D�pth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIRIADDITION ! I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial _ Other Number of living units: " 1 Number of.bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I` Distance to nearest: Well _ Foundation Property Line LEACHING LINE ❑,II N9. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL, PONDS ❑' ' I hereby certify that I have prspared 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,a signature certifies the following; "t 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 taws 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust I or/all equuad ' spections. Complete drawing on reverse__g de. f Signed X-4. J � _ — Title: z Date: DEPARTMENT USE ONLY 1 Appliccl ation Accepted by Date a 2- Area _ .ii Pit or 62t Inspection by "i ate �Z Final Inspection by rio ate � v _qvb i,. Additional Comments: F Applicant - Return! all copies to: San Joaquin County Public Health Services Environmental' Health'Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 }9L? J FEE AMOUNT DIE AMOUNT REMITTED CAS49 H RECEIVED BY DATE _ PERMIT"iVO, C� l INFO . EM 13•24IREV.linsi EH 14.26 O , �, I� vV