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; f APPLICATION 9�f0 - 9 SAN JOAQIIIN COUNTY PIIBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN - PHONE ( 209 ) 468- 6 D CO --- --- --- P 0 BO% 2009 , STOCKTON , CA 95201' C{� � PERMIT EXPIRES 1 YEAR FROM DATE ISSIIED � ( Complete in .Triplicate ) KOC, - - Application 1s hereby made , to San Joaquin County for a permit to construct and/or Install the work n '3�s bed .- -This application is made in compliance with San Joaquin County. Ordinance No. .549 and 1862 and the . Rules . Joaquin County Public Health Services - - . - - Job Address �Q W • l � A-1 '� W41 l - --City A � 0 Lot Size/Acreage C ` (] Z0 Owners Name t�omell.uu. " C)o>,s�'YVcEon - Address PO UOX— IJoti S+OC.��T0r11Phona �L4 ` Contractor &(,w On IIOCA - • Address;S.1471W1 :Q7�( ll:t � 4 _ iLicense No. �_/ � Y— Pho kid t•Y TYPE OF WELL/ PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ - - - PUMP INSTALLATION - SYSTLNI PAIR ❑ OTHER ❑ Moni7teyorf.ng Well DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES - J-aDISPOSAL FLD. �/� PROP. LIN �v /� FOUNDATION Q.' AGRICULTURE WELC�4 + OTHER WELL 15 r PITS / SUMPS3 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC 10 S ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,❑ Domestic/Private a,,g Eravel Pack ❑ Tracy Type of Casing Specifications f/ PI Public _ ❑ Other n Delta Depth of Grout Seal © � Type of Grout I I Irrigation _. Approx. Depth I 1 Eastern Surface Seal Installed by S�•YA t/L Repair Work Done ❑ Type of Pumpn .f a H. P. � - - - —�-- -- State oW rk Done _ Well Destruction ❑ Well Diameter -�n Sealing Material . i Depth - - - Depth s o I Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I 1 ( No septic system permitted it public sewer is available within 200 feeGl �,. Installation will serve: Residence _ Commercial _ Other - - Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 . . -„_ _ _ ._ _ ._". Method of Disposal Distance to nearest: Well - - Foundation Property Line LEACHING LIN_ E - ❑ No. & Length of lines Total length/size - - FILTER BED--- --- - ❑ Distance to nearest: - Well Foundation Property Line - - - SEEPAGE PITS - 11 Depth Sus Number SUMPS I ' LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - - 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California. " Contracto(s hiring or subcontracting 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 Californk.” The applicant must call for all required ' actions. C plata drawing on reverse side, Signed Title: Date: J PARTMENT USE ONLY Application Accepted by Data i I -i � Area l Pit or Grout Inspection by � �p Q Q� � Date ,�j f -/ �' Final Inspection by `/,"/'tery�'�" (i/ ' I I.�I,P�O il' Dates Additional e n v"�K 010 r�Y Ut 10 � <&AAA Ap n r % op an &44 u y blic Health Services L4'=Mr- Environmezltal Health Permit/Services - - 445 N San Joaquin , P O Box 2009 , Stkn , CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED aV DATE PERMIT' NO, ST . EH 13.241 IREV. 1 / na) ' IZZ L I _ 85 EH 14 20