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II i i� APPLICATION II i SAN- JOAQUIN COUNTY PUBLIC HEALTH YdVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 . Ij P O BOX 2009, STOCKTON, CA 95201 { II PERMIT EXPIRES 1 YEAR FROM DATE ISSUID" (Complete in Triplicate) li M I Application is hereby mads to San Joaquin County for a permit to construct and/or install the cork herein described. This application is made in compliance with San Joaquin County Ordinance No.- 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 7^ j1 Job Address 63� So6TH EkbGR j FT" City txf1t6•J Lot Size/Acreage Owner's Name �� 'J PIA,11 6 Address 3 $6(,-VH FLIM A 6 b S_r _ Phone Ij r II, ContractorFepLT t n D ltt-6N 6 Address�•O-$G- aL X165[70 _License No.X889?q __Phone - TYPE Of WELL/PUMP: ANEW WELL C3 WELL REPLACEMENT Cl DESTRUCTION m Out of Service Well Gl r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ZOCI+ SEWER LINES �� DISPOSAL FLD. "! PROF.,LINE I FOUNDATION -ZO—PT AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ industrial © Open Bottom' ❑ Manteca Dia. of Well Excavation ra- Dia. of Well Casing Z l AnL 1`a Domestic/Private Cl Gravel Pack I-] Tracy Type of Casing_ - Specifications [GREa .16 _ 1'1 Public 'I IN Other fl Delta Depth of Grout Seal 36 Fczr-- Type of Grout RI?. t I Irrioation Approx. Depth 11 Eastern Surface Seal Installed by IGH R Ip 3 Repair Work Done 0 Type of Pump H.P. �— State Work Done Well Destruction ❑ Well Diameter Sealing Material b Depth �3i+'!aZbiul� 3 _•36 I Depth Filler Material i Depth `3 .SAS 6°-38 TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is I Ij available within 200 feet.! It Installation will serve: Residence 'E Commercial_ Other _ 1 4 Number of living units: Number of bedrooms d IE Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments '! PKG. TREATMENT PLT. ❑ Method of Disposal II r Distance to nearest: Well Foundation Property Line �M LEACHING LINE ❑ No. & Length of lines Total length/size .v FILTER BED 0 Distance to nearest: Well Foundation Property Line ail SEEPAGE PITS I I Depth 'I Sire Number I. sk SUMPS 4� "w -._ LI—Distance_to nearest__,We4!- = 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 Il 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 persona subject to workman's compensa- tion laws of California." !! i The applicant must call for all required inspections. Complete drawing on reverse side. } i Signed 1 I Title: GF.aCd6lSGeA L 1�a1L ©tu,u82 Date: II .� FOR DEPARTMENT USE ONLY � Ii Application Accepted by "4 �41 Date Area L'O,Pao� a Pit or Grout Inspection by �C Data Final Inspection by Date !! Additional;Comments: + Applicant - Return all copies to: San Joaquin County Public Health Services 7 i' Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 it .4 i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. . EH13.241AEv.rinal q►oG .P/V EH 142a �I