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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) k a,Application is hereby made to San! iJoaquin County for a permit to construct and/or install the work herein described. This ;: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. p ~/�cd1 e!�/� ,G� Born A PRO Job Address r7li L _____L�t LSE ��fi C City LOC-kF601,ot size/Ac a ,O`wner's Name Address N CJQf' CC Lejo;,�l 'Phone^� Contractor �E' Address 1« License No. _ Phone '112 TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION 9?' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. � PROP. LINE AJLf FOUNDATION «- AGRICULTURE WELL OTHER WELL PtTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS AL1 industrial "pen Bottom ❑ Manteca Di ia. of Well Excavation Dia. o!Well Casing V'[ Domestic/Private 0 Gravel Pack L1 Tracy Type of Casing- S t SPL Specifications. I'1 Public fa Other 1 F-I Delta Depth of Grout Seal 100 Type of Grout_T I I Irrigation T...Approx. Depth l I Eastern Surface Seal Installed by A24(4<r:q R Repair Work Done 0 Type of PumpjA±,J� H.P. 6 _ State Work Done Well Destruction ❑ Weft Diameter Sealing Material & Depth - - ,-Depth- Filler_Material i Depth TYPE OF SEPTIC-WORK; NEW INSTALLATION I 1 REPAIRlADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sawer is t ',� available within 200 feet.} Installat' ill serve: Residence Commercial— Other r a.._r k Number.- living- "'.Is: Number of bedrooms r Character of soil to a de f 3 feet: Water table depth SEPTIC TANK ❑ Type I Capacity No. Compartments PKG.dTREATMENT PLT, Ll Method of Disposal _. 9 Distance to nearest: a Foundation Property Lina i 5 LEACHING LINE ❑ No. & Length of lines Total length/size . y. FILTER BED F) Distance to nearest: Wall Founcation Property Line SEEPAGE PITS I I Depth Size Number SUMPS tance to nearest: Well Foundation Property Line DISPOSAL P ❑ 1 i :. I hereby certify that t have 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 unifies the following: "I certify that in the performance of the work for which this permit is issued, I shall no employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting stgnatur� certifies the following: "I certify that in the part ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applicant rttu call for all r ui ed inspections. Complete drawing on reverse side. Signed Xry Title: _ Date: _5��2 F3 FO DEPARTMENT USE ONLY ■■ 11 Application Accepted by Date Z 2,T lVy � --� Arear; 5 P'tt or Ge-)u Inspection by Dated'_�A /n_ Final Inspection byDate t Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services t 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE ri INFO AMOUNT DUE AMOUNT REMITTED K -RECEIVED BY ATE PERMIT'NO. � a EH 17-24 VtEv.r 10$si EH 14-29