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APPLICATION w I - II' SAN JOAQUIN COUNTY PUBLIC HEALT ES ENVIRONMENTAL HEALTH DIVI !Tl Af"K i G � �4 445 N SAN JOAQUIN, PHONE (209) �0 P 0 BOX 2009, STOC%TON, CA EAIYIROfd"^C^!TALHEALTFI PERMIT EXPIRES 1 YEAR FROM DAIIS �r F` vi;lr ,:':;ICES (Complete in Triplicate) 4.4.{�cr.t'1 Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. Thit_"ycl' ' 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. Job Address 24F!i3 1 , 24310 ,E1 01 43 N, DE [t/ QIr5 City I oD1 p� Lot Size/Acreage 149:t AG: ms-q4 -0Owner's Name RI%Ct22 f0 - Address 21343 N, 17EVNESFV. LMIICA, Phone Contractor BnijMbCyGh 4 FICtZ.&I Address 32311.! E1rn St LOCMlicense No. 1�1E3� Phone 3(-b(-F,IS 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 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o1 Casing_ Specifications I'I Public 1-1 Other 71 Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. Stats Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLAT / DITI I DESTRUCTION 1 (No septic system permitted it public sewer is ercEalatlon Test M 5-q4- available within 200 feat.) Installation will serve: Residence_ Commerlae _ Uther Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: cTr� auj>}t SEPTIC TANK ❑ Type/Mfg Capacity PKG. TREATMENT PLT. ❑ TipLTsl Distance to nearest: Well Foundation Propllr kn4 2 1494 LEACHING LINE ❑ No. 6 Length of lines Total IerigCllllj��i AQW.1 F)FILTER BED Distance to nearest: Well FouncNA ation V' (4k 1 'I-7F STM Di\ �1t t Er,v� rr�� SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby cenify 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; "1 certify that in the performance of the work for which this permit is issued, 1 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: "1 cenify 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 call for all required inspections. Complete drawing on reverseside.+ i B Signed K /.L -.� C��I - Title: f1 Aer or B3.0 m):?aCh ROZZo te: ////1�� FOR DEPARTMENT USE ONLY Application Accepted by -C i g `r �� Date �� i 7 Area G Pit or Grout Inspection by Date final Inspection by j ' - Data - 7 Additional Comments: `S / 4 s iso— " f`-- 1 Applicant - Return all copies to: San Joaquin County Public Health Services C��\i Environmental Health Permit/Services i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE IN FIO�, AMOU UE AMOUNT REMITTED C ///iECEIVED BY DATE PERMIT'NO. • EMS IaEV.rix �v I5 I'N'D 6�Q'i 1 �l/