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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 San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address de-7 City '5V0K 11 Lot Size/Acreage Owner's Name 70 JAWC6 �E/��7�A Address P 6+ 64 — Phone ,L Contractor WISLn t�/�TA�VAPIf Address /803. W1H *--d License No. Phon 6' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLArEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 4❑ Morlitoring Well DISTANCE TO NEAREST: SEPTIC TANK /00� SEWER LINES - �_ DISPOSAL FLD.A4:... PROP. LINE 7_6T1 FOUNDATION 20 AGRICULTURE WELL AOTHER WELL...4� PITS/SUMPS c.�,* INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Are- Specifications 'r I'1 Public Other t RI Delta Depth of Grout Seal il5 Type of GroutAbArd47 G71t1- I I Irrigation —Approx. Depth- I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Q Well Destruction ❑ Well Diameter '41+ Sealing Material t Depth �C'7'.l .t C_ Depth aG 30/ Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 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 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation_r_ Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI -Distance to nearest: Well Foundation 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 st cal 140r aMrrequired in ctions. Complete drawing on reverse side. Signed �`l� Title: �JGz�r- 6uz_l- ST Date: G FOR DEPARTMENT USE ONLY Application Accepted by Date Area i Pit or Grout Inspection by 2'� -/" a Final Inspection by Date 3 Additional Comments: �'v / Z 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 CK 9 CASHQ RECEIVED BY DATE ? PERMIT'NO. a .aEM 14.3.224JBE $ � V..tinSl � _. `� // 3 EH