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. APPLICATION SAN 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 3 (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 coupliance with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services , Job Address City /1� Lot Size/Acreage Owner s Name _ >_� ��lr r JifE'J�ddress -7 PJ A ' Phon �' X16 r -_ 3 ,Lc_ 52 7 Contractor -n �?�f�LG ddress_0111 /T3GEi'4Lty—�'S License No/G'172ZOe Phone TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Wcll ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR -fTHER ❑ Monitoring hell DISTANCE TO NEAREST SEPTIC TANK SEWER LINES -So 41141u 3 I Pi rc r-OSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6tjS+Ha4/ O_T rL',r_. ❑❑Open Bottom ❑ Manteca Dia of Well Excavation r C�_ Dia of Well Casing ,CI Domestic/Private r Gravel Pack ❑ Tr y Type of Casing_ /0UC� x `�� Specifications I i Public { i Other elta Depth of Grout Seal �� ` /'.Z. r Type of Grow g:j _-47- L'�TI�Oic�t[1l//i7cs/ �J� ! l Irngatron .21'�Approx Depth I i Eastern Surface Seal installed by � Repair Work Done 0 Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth filler Material i Depth TYPE OF SEP WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system per ted if public sewer is evadable within 2 eel 1 Installation will sery Residence ____ Commercial _ Other Number of living units Number of bedrooms Character of soil to a depth o feet Water table depth SEPTIC TANK ❑ Type/ Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well F at[on Property Line LEACHING LINE Cl No 6 Length of lines Total length/size FILTER BED 10 Distance to nearest all dation Property Lina SEEPAGE PITS I 1 Depth ' mber SUMPS LI tante to nearest Well Foundation rty Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work wilt 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 Contractors 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 a compensa tion laws of California " The applicant must call for all required inspections Complete drawing pq revet(sq side I Signed X t•--.Cts -^' Title �. ,27tX1C tcrati.o � _ Date FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data 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 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NQ INFO CASH im 1724[REV 1/m5i EM is 26