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• APPLICATION • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 TEAR FROM DATE ISSUED ND SJL:e'r A-bD(Ltss (Complete in Triplicate) t(_ (3earNcs Application is hereby made to Baa Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Sm Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /6-5-,X/as' / O ~jzO-5S0u'n0;: 04-a.kA� -r'(nC Lot Slze/Acreageo ;-S arS Job Address Lo C-4101) l xH w5 aka/ of ANa Rdbp City PG+6 64SSu t r 5 1 ITe pwmr's Name PP Y QUSineSS L!n f AddressPhone_ Tres+ilr3 M4 ineie Contract a Addr s 50 License No.�}R51G5 Phone l TYPE OF E660-UW NEW WELL ❑ WELL REPLACEMENT 7 DESTRUCTION ❑ Out of Service Well O W c{ 50L1�C 3 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE/J4—TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N 4 ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Du. of Well Casing Cl Domestic/Private 0 Gr" Pack ❑ Tracy Type of Casing_ Specifications 1'I Public 1:1 Other 11 Dena Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. Stats Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material E Depth TYPE OF SEPTIC WORK/ NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo sepoc system permitted it public sewer e available within 200 fail Installation win 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.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE, f��0 No. 6 Length of lines Total length/size FILTER BED N ❑ Distance to merest: Wall Foundation Property Line SEEPAGE PITS �I�- I I Depth Size Number SUMPS gU 11 LI Distance to rwrest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I hero 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 canAws the following: "I certify that In the padormance of the work for which this parmvt is issued, I shelf not employ any person in such manner as to becor a subject to workman's compensation laws of California."Contractoes hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permdt is issued, I"if employ persons subject to workman's compensa tion laws of IHprJa." The applicen all for all r i d inspections. Complete drawing on reverse side. �- g Signed /f 1 Title: PP of f l> O Joh Date: L71�°'J� ^I61 FOR DEPARTMENT USE ONLY 11 7 Q Application Accepted by Dae L ` Area PN m Grout Inspection by Data Final Inspection by Date Additional Comments: 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 AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT No.INFO n Imo' `// PaRe 13A . EM 1124(REV.Ir as) y � � t'7 /�/ / Q�l�l �p/' 7 01, J Z EM 1e.y U