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SAN JOAQUIN COUNTY PUBLIC HEALTH S .,,_`� ENVIRONMENTAL HEALTH DIVISIONZZ -; i. c 1-. 445 N SAN JOAQIIIN , PHONE (209) 46$ -3420 P O BOX 2009, STOCKTON , CA 95201 0 S„ ty_ 1 RMYEAR-FROM PEIT IR S 1 YEAR FR M D TE ISS p-r4,...,.�.'rf;;; y (Complete in Triplicate) ^�l';r �•�.;F ;, y Application 11 hereby made to San Joaquin County for a permit to construct and/or install the work herein described! This:1, application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sa.n Joaquin County Public }Health Services. Job Address city-51DC_K7DrJ Lot Site/Acreage Z z Owner's Name Ch6r IZO r`-� U & Pr Address 1� Phonr(, ro — t STer•J 21'+rrnor.�� CA 4.�`4Ss-{.` C� Contractor KV %LVA Ra W � E.t+-�, Address ►} 0� LkTJ ►.-t t -r.', DNL( C License No. 757-+1Q'Z'`iO Phon Sri' TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT Ct DESTRUCTION ❑ Out of Service Well Li PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES '2 ton DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ Manteca Dra. of Well Excavation c Dia. of Well Casing k:n QV C_ Specifications r.) Domestic/ Private I'1 Pubfic ❑ Gravel Pack ❑ Tracy ,'1�Otl+er Type of Casing_SCH Depth of Grout Seal S-0 rPL:T- Type of Grout Nor= Cafne" I I irrigation Approx. Depth XEastern Surface Saul installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Scaling Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i l DESTRUCTION I I [No septic system permitted if public sewer is available within 200 toot.) toInstallation will serve: Residence ^ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ TypelMtg PKG. TREATMENT PLT. ❑ Other Capacity Distawa-1-6 nearest: Well Foundation LEACHING LINE Cl No. & Length of lines FILTER BED ❑ Distance to nearetsi.�- Water table depth ,. No. Compartments Method of Disposal Property Line Total length/size_ Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest. Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application And that the work will be Cone in accoroance with San Joaquin County ordinances, state laws, and rules and regutalions of the San Joaquin County Home owner or licensed agent's signature certifies the following- "I cenity that in the performance of the work tot which this permit is issued. I shell not ernOtoy any person in such manner as to become subleCt to workmen"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, t shall employ persons subject to workman's compensa- tion laws of California." The applicant� ust call for all required inspections. Complete drawing on reverse side. Signed K__ Title:Ja1^f Date: Q]� ST �! f/fC�.L.L/IY��7� FOR DEPARTMENT USE ONLY Application Accepted by ,._:T•� - Dare _"D ' Area ` •� Pit or Grout Inspection by Date Final Inspection by Date �ddrvonal Comments: 5 + rZ Tr22rl Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. LR .12 qz 36,3 Fn 1�•7e