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_ APPLICATION y� SA`1 "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 made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ccupllance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Serres. Job Address C ✓ N ". �'a b Q�"�A �1'� I��City 5 �� `'� Lot Size/Acreage Owner's Name Lko tPaLchC�>1DW'� Address 1000 Me'"-anl`de ( �ul PhonetS S71-Zg69 G ; !,. 32111 r-J+ a�rc.1J a.4 ;}z Z K 4+f0z- ii�j fb> Contractor Address D�z.C�c �v�,1r C'aQ� l�tL License No Phone SZ-7r-IS`� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �>SD DISPOSAL FLO. PROP. LINE "--30- FOUNDATION -3vFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -40-11 4cr,VO pen Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Z rl Domestic/Private ravel Pack ❑ Tracy Type of Casing_py�- 5C4 ur3 Specifications r I'I Public �(�l Other Delta Depth of Grout Seal %�—�L Type of Grout _ I I Irrigation 2L Approx. Depth I I Eastern Surface Seul Installed by Repair Work Done U Type of Pump H.P. - State Work Done_ Well Desttucuen O Well Diameter Sealing Material i Depth Depth filler Material i Depth TYPE O ' EPTIC WORK., NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve, idence_ Commercial_ Other Number of living units: bar of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Fou on Property Line _< i—j LEACHING LINE ❑ No. & Length of lines To ngth/size FILTER BED ❑ Distance to nearest: Well Foundation Pro Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ I hereby certify that 1 haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 nec�. employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature II certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persona subject to workman's compensa• tion laws of California." The applicant must call for all required inspections. Complete rrawi �on arse side. Sig `f Ue: lb�cc�- f�(u e.r Date: 12-(-119q Application Accepted by FOR DEPARTMENT USE ONLY( ,!/(1�/1) Date ` I�`� O Area Pit or Grout Inspection by y �/• Date Final InspecGtionn by tz,"� f��t.l OGJL. • tO l ` Additional Comments: ✓h C , Applicant - Return all copies to: San Joaquin County Public Health Services MIJAM Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH EN RECEIVED BY DATE. PERMIT NO. EN112�IaEV.tK�et � f l L/ g4� `Z.�2• ` � �59� EH 147a