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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y �/ ENVIRONMENTAL HEALTH DIVISIONS 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 vork herein described. This application is made in coupliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. C1 .2 InS ter-'✓��\rc w. tk ti�u�:� fir City •,1'D�(Cr 1-0-• Lot Size/Acreage 0. 16 Ace-i Job Address I?O- $rsll Sffll, �fs S!�-'LR-Ibr Owner's Name ��+��a`�"`�' Cv.«�. ,�_ Address 'h �'° u CSL clay d x Phone -3 nl,4 12.I . 4e-L II Contractor i,Yrusr Co to do -. Address Pc.,.l+O, ( �la,> >. • ?=License No—. Z.-Tw Phone`410 952.-74S-4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 04a�A OTHER 0 1_Monitoring Well 1K DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES [�ISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r�.� n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4 -r�� Vt1eeX, ' Dia. of Well Casing ['I Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing_ PV L. Spa if' tions — I'l Public Ia Other Delta *cv'b Depth of Grout Seal ilccfiutulZ4'r •hr 4Qype of-Grout 1 I Irrigation. _Approx. Depth I I Eastern Surface Soul Installed by�`•t•r1^-e✓ E)Celorv4 vy* 1fY�G.1 i ' n Repair Work Q�ne 0 Type of Pump 60—e— H.P. State Work Done [�. _ Well Destruction ❑ Well Diameter Sealing Material i Depth a.Ly-f N-0 Depth Filler Material i Depth API L-„ Start 50..-. TYPE OF IC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: idence_ Commercial_ Other j Number of living units: mber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. b Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Numbs SUMPS LI Distance to nearest: Well Foundation Property ' DISPOSAL PONDS ❑ 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: "1 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 workmen'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 applics t must call fpr all required inspections. C1o1mpl tot dra�w�p on reverse side. 1_ j f Signed X�,W�1 &I �wc sx Ca•�d Tiile`'�roacc��s%�D�t J T Date: � 1 Z Iq `A FOR DEPARTMENT USE ONLY �j Application Accepted y DateA� �� Area �✓r _ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 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 CASH RECEIVED By DATE PERMIT'NO. INFO {{�� n / . EH 13-24IREV.I/net � eft �I/l!/Q $.1`q(- M3'VG EH 11426 1111•000,�� J