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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ? PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby trade 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public wHealth Services. �- Services. ` Job Address 29 �51F"6 ' s � f' t� - City 1,.11Z,;;11 Lot Size/Acreage Owner's Name Address,FEZ M ODU}F* /rye Phone'>> � aVF -License L—ri�f s N. Contractor Addres � License NcZ � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ['I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications 1'1 Public f-1 Other 171 Delta Depth of Grout Seal Type of Grout ' I I Irrigation —Approx, Depth 1 1 Eastern Surface Sedl Installed by i Repair Work Done U Type of Pump H.P. _ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth a� Depth Filler Material & Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR I ADDITIONA DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X. Commercial_ Other Number of living units: _/__ Number of bedrooms ,'� Character of soil to a depth of 3 feet: 'lei _ Water table depth SEPTIC TANK.�I&J-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 !!5-'e SEEPAGEPITS 11 Depth r� Size �x � / Number � 3 SUMPS X Distance to nearest: Well Foundation 0,01:* Property Line ialt"' DISPOSAL PONDS ❑ 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 certifies the following: "I certify that in the performance of the work for which this permit 13 issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican nust call for all r uired ns tions. Com to drawing on reverse side. Signed Title: ' Dole:V V_ 2 , OR DEPARTMENT USE ONLY 1� D Appli ion Accepted by �QAA `VV\ . a._. - Date Area •�� or Grout fns ction by f'-2'2 .Date 047 Final Inspection by . �� 1 e• �Z j Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 945 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE i CK 9 INFO AMOUNT /j�}DtJ�E} AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. . EH t3-2a IHEV.1/8 sr ! ✓ pq r 1��- L1 EH 1428