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�., APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P 0 BOX 388,STOCKTON,CA 95201-0388 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 work herein described.This application is made in compliance with San Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. �, Cj C �#S r D�/ r'Qi✓1 RJ • City— G Lot Size/Acreage Job Address ` Owner's Name ' '�e� Grp Y©n Address i�- 7 h I? w' Phone 3 7 ��1o+��T:ah 130 3 V'- M4r-A 1-K. L License 5 ,-i7 Phone 956-07.6 , Contractor &,,o/� tdj/Se It� Address �O License No. TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR. O OTHER ❑ Monitoring Hell FL DISTANCE TO NEAREST: SEPTIC TANK ►4 T SEWER LINES DISPOSAL FLD.�_ PROP. LINE 3_ FOUNDATION 9 AGRICULTURE WELL OTHER WELL Q PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation �r Dia. of Well Casing ("1 Domestic/Private 0 Gravel Pack A Tracy Type of Casing_ f y C" Specifications \ V I'1 Public Cl Other F1 Delta Depth of Grout Seal 3 TYPe of Grout -P0rTt4hc1 4 I I Irrioauon 101 Approx. Depth I I Eastern Surface Seul Installed by E I l5h 2,-e) y/ti+i La✓�N Repair Work Done U Type of Pump H.P. State Work Done_ n � Sealing Material i Depth For�rigNcl 1;#_ f Well Destruction O Well Diameter 5d�� 3 Depth _ Filler Material i Depth �or1 TtNe TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADOITI3N I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line v Q LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founaatlon Property Line O SEEPAGE PITS 11 Depth Size Number (1 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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, 1 shell 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 compenta- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X sv(r''►� �z s,�l ./.I�.�. Title: Jl uFf G,ec i0 5 i Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Z�123 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental -0388 UHealthPermit/Services ��^) 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201 <^ FEE AMOUNT DUE AMOUNT REMITTED t RECEIVEDBY DATE PERMIT NO. 2 INFOOC-) 11�Zl 1 a. CASH EN 17-24 1111:v,I/M SI W,I I EH 14.70