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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � A 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. Zhis application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 Job Address �qM �e��C` ""t' u01� Drvt City �tc�cJZ�or, Lot Size/Acreage 0 to�CYeS A sLCO P✓'cc�: -j) �n . cin Address 'F01?e X SST SG,-. Pa��0.(�-411 go Z Phone Owner's Name �—Q i Contractorwo Address P . e7tr Ccls-(yg 376 5q5', License No. -"Y7 Phone(9/10 -9355 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEER ❑ Monitoring Wells 5b�2 �eaS ..-SpFrt+,ia3,ifat�er• sL*1 e��lr.11 l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES e MDISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Xiµ q14,41" n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - -� Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ S,�py��ifications �tyL I'l Public f-1 Other >(Delta%J�� Depth of Grout Seal t4atvi c.b`er•,..-Gi�Q�'type of Grout 1 l� �ailion «3A Approx. Depth I I Eastern Surface Seal Installed by Wu a Vr. r,-w k1�Repair Work D e U Type of Pump 1.�0�� H.P. State Work Done _ lU Well Destruction ❑ Well Diameter Sealing Material i Depth 15e-ko�.�e Pw�- ✓ Ucw:c� �- �D Depth Filler Material & Depth }k (.r-e Ste✓ TYPE SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system mitted if public sewer is v� available withi feet.) Installation wi rve: Residence_ Commercial_ Other Number of living unit Number of bedrooms Character of soil to a dep f 3 feet: Water table depth SEPTIC TANK ❑ T fg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to near Well F ndation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: allFoundation Property Line SEEPAGE PITS 1 1Dept Size Number _ SUMPS =stance to nearest: Well Foundation Property Line DISPOSAL PON ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San aquin 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicantT(��,ust call for all required ins ctiofnls. Completed rfaw= on verse side. Signed X�Y�,r" //�`^iS t� N--G-rjL`Title 2 f 6V`�tL �i 1�T <+nG<if Date: O FOR DEPARTMENT USE ONLY ) D Application Accepted by tr ' Date / C' Area v Pit or Grout Inspection by Date Final Inspection by1yy Date Additional Comments: w 41`J (n5�On if-,c D ICSH 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 i CASH RECEIVED BY DATE PERMIT NO. INFO QC H EH 13-24MEV.=iAS) S�� g-1 OC7 �C) ►' ` -1 l' tJ� I�� EH 14.26 L ll