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x APPLICATION S`JOAQUIN COUNTY PUBLIC HEALTERVICES ENVIRONMENTAL HEALTH DIVISION �CQ 445 N SAN JOAQUIN, PHONE (209)468-3420 e • P O BOX 2009, STOCKTON, CA 95201 (0'%� 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 conpllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 0V cft*x,iCA-'" I%` 4r'tjr Dif- City Lot Size/Acreage 0. 6 Aw-res, A Sam +u 4: Cm 94ie Phone 44()s 2.,46 cl Owner's Name �_ Address a -i- 3'L 41 :- +�ga ro lr� ted. Su 64 ie 2_ Contractor rtt,"ae- r.wtle'n'ira"% Address Qprcl+or Calacy.9� ;(!&•9S7'JZ-License No2n24=� PhoJ4l(.)gSZ-7` ,S4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER Monitoring WellA4 6e Td DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES UISSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V-1% I nZrr Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation 10 WtRX' Dia. of Well Casing fl Domestic/Private O Gravel Pack O Tracy Type of Casing_ PV t- �S,pecif' tions I'] Public f �I I Other "�((Delta *-+ Depth of Grout Seal 1<crtablE-E+c�"��. y"�'pe of Grout IIrrioaatti�on _Approx. Depth I I Eastern Surface Seal Installed by 1&rY%Z✓ 1EXeloreA oy� �Repaii Work Wne O Type of Pump 010"R- H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth eo""L .. y rin le_) Depth Filler Material & Depth d-1 $lL.,.1. TYPE OF TIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: idence_ Commercial_ Other Number of living units: mber 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 Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Numbs SUMPS LI Distance to nearest: Well Foundation Property DISPOSAL PONDS O I hereby certify that 1 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 is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica t must call for all required inspections. Complete ddrratwJing on reverse side. ` t� n Signed X �,,.a:6s^it 4�-��jgzQ ." Title: �rob�� c (t11`J T- Date: b 17-I�t 'I - FOR DEPARTMENT USE ONLY Application Accepted by Date �� Area Pit or Grout Inspection by Date Final Inspection by71 _7T Additional Comments: =5216 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 INFO FEEAMOUNT DUE AMOUNT REMITTED CASH {yRECEIVED BYDATE/ PERMIT NO. . EH 13-2/1REV.1/"5) �1A US1q_S EH 14.25 �l't.�''-