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APPLICAT'ION SAJOAQUIN COUNTY PUBLIC HEAL'OSERVIBRW 00 /7 �__ 3 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46873 # P 0 BOX 2009, STOCKTON, CA 95211��,((�� PERMIT EXPIRES 1 YEAR FROM DAT IS'0'ID,'I # (Complete in Triplicate) INV # Application is hereby made.to San Joaquin County for a Permit to construct and/or Sas s application is made in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulation. of San Joaquin County Public Health Services. I '/ Job Address 3e/I 10' 6 L0:7 AA4/,1 z;r Ox ' City 5�c�TTAJ Lot Size/Acreage lucv 1I. lei' Owner's Name .5Wr&— 4914- COM,04AJ 7/AAddress RE ;RS2 46 S`� Phone 674)4 75-Z/7Z v 1 Contractor AF��.S ��✓i,Ed�t1M4�iY`TX2address %C Mc��"��4,`'�SSZTLicense NoC�� Pnonk/G rJl'-L'2J/t= TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT it DESTRUCTION C Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well , DISTANCE TO NEAREST: SEPTIC TANK �'' SEWER LINES MSc DISPOSAL FLO. lot PROP. LINE r FOUNDATION FT AGRICULTURE WELL _yl OTHER WELL—ALLI— PITS/SUMPS 6� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � / ❑ industrial ❑ Open Bottom C) Manteca Dia. of Well Exca�Sion 1 2 i.J- Dia. of Well Casing Y iNcl� �l r . Domestic/Private C. Gravel Pack ❑ Tracy Type of Casing �' Specifications —ALo rig Public '�l Other r)(Delta Depth of Grow Seal /0 f r Type of Grout I I Irngatron Approx. Depth I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump A' H.P. At 0 State Work Do's�, W Well Destruction ❑ Well Diameter S i It wing Material L Depth +�iSA1 ta. ID O Depth Aa - ZS r Filler Material i Depth PDA-SLMUD GF�dsE.V.i TYPE OF SEPTIC WORK: REPAIR/ADDITION I I DESTRUCTION I I INo Stli sYaem permitted it publid sower is available within 200 feet.) Installation will serve: Residence_ Commercial_ Others ' Number of living units: � Number of bedrooms K44I Character of wit to a depth of 3 test: ar Water table depth + ^" SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal a�C Distance to nearest: Well Foundation Property Line aA iyMEN T LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 1E�(7 Property Line nEC 0 1 IJ33 ,ITS SEEPAGE PITS 1 1 Depth Sire Number �� i� '-!cALTH `cF.VI ,1 SUMPS L' Distanu to nearest: Well Foundation Property Lim r,AL HEALTH DIV DISPOSAL PONDS ❑ 1 hereby certify, that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, anc rules and regulations of the San Joaquin County Home owner or licensed agent's signature csrnfies the following: '9 certify that in the performance Of the work for which this permit is issued, I shall no employ any person in such manner as to become wbtect to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I small employ parsons subject to workman's compsnsa tion Iowa of California." The applicant roust tali for MI rjocluoirld inspections. Complete drawing on reverse side. D .f Signed X `.% t Title: `.Y2�,(� Date: 11h-5 1--7 FOR DEPARTMENT USE ONLY 9q ��C` Application Accepted by Date /y !3 Area " lcl Pit or Grout Inspection by Date _9 Final Inspection by Date Additional Cominen4: Tunty Applicant - Return all copies to: San JoaqPublic Health Services EnvironmHealth Permit/Services50 445 N Sauin, P O Box 2009, Stkn, CA 95201 FEE AMOVNT DUE AMOUNT REMITTED CKCASH a RECEIVED By DATE PERMIT NO. INfO . EH,}].IeEV.�r.sl EH 14]a