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APPLICATION ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION - f 445 N SAN JOAQUIN, PHONE (209)46$-3420 " P O BOX 2009, STOCKTON, CA 95201 u PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'qo (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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. t Job Address j03 Ci[ 4nyj Lot Size/Acreage Owner's Name Address,,?O, k.%JC f C Z r S4C MITIe4 Ti!7I Phone a eff7 zap Contractor 71r ddress yk(AkA License No. 19 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'❑ ;DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 '7CJEPDISPOSAL FLD, PROP. LINE . .. __,.-w. ,---EOUNOAT_I_ON AGAICULTURE'WELL;- ""..OTHER.-WELL- — ;P-ITS/-SUMPSc.,!:—L_--� ._. --rt- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ L7 Industrial a. 0 Open Bottom — ❑ Manteca Dia: of Well Excavation _- _IU f' pia. of Well Casing [I Domestic/Private X Gravel Pack ❑ Tracy Type of Casing PW #!qD Specifications Vfo f'I Public 1-1 Otl)er fl Delta ,Depth of Grout Seal g_ _ Type of Grout. I i Irrigation VApprox. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter _y �� Sealing Material & Depth Depth ss" Filler Material b Depth 74 TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION I I DESTRUCTION i I INo septic system permitted if public rris—� available within 200 Installation ill serve: Residence Commercial__ Other Number of living Number of bedrooms PYET Character of soil to a depth o SEPTIC TANK. ❑ T ype/Mig: Capacity SNC. Compartments PKG. TREATMENT PLT. Ll f IM1doe�90,2 Distance to near Well Foun PF A4dt'd(SIitiQ1 11 fI,,;'i LEACHING LINE 0 Length of lines Tot&W NL,L si is f°'l�!,JN FILTER BED Distance to nearest: Weil Foundation Property Line SEEPAGE S i I Deptli Size Number r SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ <" i'hareby certify that-I havepropared-this applicafion"antlihat the work will'be-dane in adcordance wif San Joaquie county oidmances, 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 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 California." - The applicant must call for required inspections. Complete drawing on reverie side, Signed X,A,011Title: r Date: FOR PARTME T LY Application Accepted by t Data r Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Y Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box.2009, Stkn, CA 95201FEE w. , INFO AMOUNTDUE AMOUNTREMITTEDCLK 9 ASH RECEIVED 9Y 1 DATfE� PERMIT'NO. .• CH 13 24 14"16SREv.YF insl „fir �� rt/O EM