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=' APPLICATION Ll � SAN TOAQUIN COUNTY PUBLIC HEALTH SSERVICES� ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ' f1 PERMIT ExPIRES 1 YEAR FROM DATE I SSUED (Complete in Triplicate) Application in hereby made.tc San Joaquin County for a permit to construct and/or install the vor k herein described. This applleation Is made-in compliance vlth San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services, Job Address —AF7) Lovi,s e A-ye no e_ I� ! City (LD Lot Size/Acreage ! CuCs'4 Owner's Name Address 1 Phon 4r'S 57/-Z9 05— =,p r. � ,� r f � Contractor �� 1 Address License fVo.J��Z•(orc Phone lf,,16 4 P f� TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION 0 Out of 'Service Well ❑ PUMP INSTALLATION_ ❑ SYSTEM REPAIR 0 (6 1rebdf)OTHE4 P; Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. t�PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL I'FPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ii C7 Industrial ❑ Open Bottom 0 Manteca pia. of Well Excavation fo—t>!► -I— Dia. of Well Casing Ci Domestic/Private ® Gravel Pack ❑ Tracy Type of CasingIrl0n.4 — _,.._ Specifications I'f Public Other bpC010k. f1 Delta Depth of Grout Seat 19Type of Grout I I Irrigation 1Q Approx. Depth Ix Eastern Surface Seal Installed by J Repair Work Done v Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter sealing Material i Depth !j Depth Filler Material A Depth �I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIAODITION i I DESTRUCTION i I (No septic system;permitted if!public sewer is available within 200 toot.) Installation will serve: Residence Commercial— Other 1 Number of living units: Number of bedrooms I� i J1 Character of soil to a depth of 3 feet: Water table depth d. SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line 'I LEACHING LINE 0 No. 8 Length of lines Total length/size F FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number ^� SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ Ji 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following: '9 certify thatin the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws of California." �I The applicant t call for all reVired inspections. Complete drawing on reverse side. ,h Title: �` Signed ,/y/C� - � Date: RTMENT USE ONLY Application Accepted by Date � i' Area '31 b Pit or Grout inspection by & ' L,,4�te Z Final Inspection by CT Date r 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 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE �� W PEAWI'N0. ` n CA �i 'I 24 fREV.+in sl ECH 13. H 11. •f�L� ` ��6)