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APPLICATION S�JOAQUIN COUNTY PUBLIC HEAL' 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 •"��✓- 31 /-fw-�{ (Complete in Triplicate) Application is hereby made,to San Joaquin County for a perait to construct and/or install the work herein described. This application is made in co=plisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1-111 Job Address City:` !/1� Lot Size/Acreage "' Q 1 A�yi t�� ( .✓:!t nAddress .&3_7 N Owner's Name _) STS✓_ � L r. c;s Z7 Contractor //!,'/LSC License No.�r'_>_77�Ci�Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Fl DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR pTHER O Monitoring Well O/�r<�{u—-1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES<�D � �(W 3 ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS el dyyEriel Jpw;TCS O0�Open Bottom O Manteca Dia. of Well Excavation (5 Dia. of Well Casing �F.l Domestic/Private Lf Gravel Pack O Tr y Type of Casing_ �U�n �i-�O Specifications ('1 Public 1.1 Other eha Depth of Grout Seal /rJ '�Z Type of Grout A11 =T' 42-116,, I I Irrigation iLPprox. 7A Depth 1 1 Eastern Surface Seal Installed by17• rL'i✓O�/L- P Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE OF SEP WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system per it public sewer is available within 200'feet.) Installation will sery Residence _ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth o feat: Water table depth SEPTIC TANK O Type/ Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well F anon Property line LEACHING LINE O No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell dation Property Line SEEPAGE PITS 11 Depth Size tuber SUMPS LI tante to nearest: Well Foundation rty Line 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, d rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I cavity 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 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 is issued, I shall employ persons subject to workman's compensa• tion laws of California." The applicant�m�u+st call for all required inspections. Complete drawing pq rev side side. Signed X�C3��.--f?� jl+/� t-�ri—^� -..,. � 4tr P-n t Ge�- �"tn-t_C,�,y� Date: If I L30 le, 1 ` T / OR DEPARTMENT USE ONLY / 51DApplication Accepted by LDate ` �• �� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: f / Applicant - Return all copies to: San Joaquin County Public Health Services , Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK s RECEIVED BY DATE PERMIT'NO. INFO �//y�� gC�fA/S,H, . EH I3-24 IttEV.t i w sr 12-- 12..., EN 14.25