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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 (Complete in Triplicate) Application is hereby msde.to Sa.n Joaquin County for a permit to construct and/or inetall the work herein described. This application is made in compliance With San Joaquin County Ordinance No. 54 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. l Job Address 2. 320S ��4�� .�l tF'�� _ City � -61 Lot Size/Acreage le 30 Owner's Name 0; Co,,, Address I v r 00 �nb '=*q r r y Ph— 1 u W�/ap i to .3m 70q Contractor %* g on r,4msAddress Lic nse NoC V)-512 6 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11 DESTRUCTION C Out of Service Well ❑ r �- PUMP INSTALLATION_❑�� - SYSTEM- fRA•IR-L-)— a --:'Monitors Well- 9S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES *'r'yfol� ISPOSAL FLDk . _ PROP. LINE 2'0 FOUNDATION r� AGRICULTURE WELL tY OTHER WELL ,_,., PITS/SUMPS <L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C3 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casin to Domestic/Private El Gravel Pack L7 Tracy Type of Casing-'��'4fa®.1_Q"� Specifications 1'3 Public l-1 Other I 11 Delta Depth of Grout Seal 3 .41 Type of Grout I I I Irrigation !A�PApprox. Depth I I Eastern Surface Seat Installad by Repair Work Done 0 Type of Pumps H.P. 11 -1te WariDone Well Destruction ❑ Well Diameter! Sealing Material 6 Depth .rtSf•��ay,� C� 401111116111 Depth 4 Filler Material & Depth r-a~.� /�P•df �lrtr�oa.�J TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOiTION I I DESTRUCTION I I (No sepsis system permitted if public sewer is available within 200 feet.) Installation will serve: Residerici Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ! Water table depth SEPTIC TANK p Type/Mfg } Capacity No. Compartments PKG. TREATMENT PLT. ❑ Meth pi,Q Distance to nearest: Well Foundation Property Li x WIF LEACHING LINE ❑ No. $ Length of lines Total length/size FILTER BED n Distance to'nearest. Well Foundation Propert Line I AN J0T7TR_C_MNTY SEEPAGE PITS I I Depth € Sire Number I$103d — -SUMPS _ . _� _LI Distance to nearest: ;Well- 9 Foundation a -- Property Line--. --�-.:�- DISPOSAL PONDS ❑ I hereby certify that I 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, 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. I shall employ persons subject to workman's compensa- tion laws of California." The applicant must cgAjora _rions. Complete drawing on r arse sid . Signed Title: Date: FOR DEPARTMENT USE ONLY d I Application Accepted by Date r Area ` 0, Pit or Grout Inspection by Rate Final inspection by Date Additional Comments: +ti.r� ►'vj G Or Applicant - Return all,.copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 33 iN d 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK If INFO CASH RECEIVED BY DATE PERMIT-NO. }� . EH 13.2 (REV.i n 51 p.+ Jf •D� ��j�?r d� `�Qj , EH 1 .26