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APPLICATION FOR PERIL Z T 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_EXPI RES X YEAR_FRO1[ _DATE ISSUED (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 Ro 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services Job Addres "ell - �v��/�� City Lot Size/Acreage O4�jtwner,�Qa Address �y&� L'/�t4CC�.JL•�- � C 6rtia - Conlracttxf.�Q�?�,�Q.�?� �.PL�__Address r +cense No Pho�e ' ' y`'�30 D TYPE OF WELL/PUMP NEW WELL .-0' WELL REPLACEMENT 171 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER � d.*4-1, 6 � DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-1 Industrial ❑ Open Bottom ❑ Manteca D+a of Well Excavation Dia of Well Casing n Domestic/Private Gl Gravel Pack ❑ Tracy Type of Casing Specifications I 1 Public n Other fl Datta Depth of Grout Seal 4r4-Y3 _ Typo of Graut�_, CrP�rJ -- I I Irr+patwn _Approx Depth I I Eastern Surface Seal installed by Repair Work Done U Type of Pump H P State Work Done _ We" Destruction © Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted d public sewer is available within 200 feel I Installation will serve Residence _ Commercial — Other Number of Imng units Number of bedrooms Character of sail to•depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundetwn Property Line LEACHING LINE ❑ No 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS I I Depth Sue Number SUMPS LI Distance to nearest Wall 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 Homs owner or licensed agent s signature eendies 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 became subject to workman's compensation Laws of California ' Contractor's hiring or sub-contracting signature certrl+es the following 'I comfy that in the performance of the work for which this perrtwt is issued, I shall employ persons subject to workman s compensa tion laws of Calif omla" The applicant must call for all required inspe tions Complete drawing on reverse side 5pned ��,1✓.J�� __ Date FOR DEPARTMENT USE ONLY 7 2, `1�`�� Application Accepted by _. .____ Date q MoL Z-' Area v Pn or Grout Inspection by Date Final Inspection by Date •Additbnal 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 INFO AMIk/#147 DUE AMOUNT REMITTED rCCAjS_(H RECEIVED BY fDATEPERMITNO -413-24 II1EV heel 6. OV c l• 0 L4-q r'�•' , o-472 Iql, �J Is 14 26