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APPLICATION r N to N -� .l I --R # SAN JOAQUIN COUNTY PUBLIC HEAL SERYCES /J� ENVIRONMENTAL HEALTH D I V I ,ION) =/ 7 445 N SAN JOAQUIN, PHONE (209 68 20 P O BOX 2009, STOCKTON, CA 944-3 PERMIT EXPIRES 1 YEAR FROM DA E ED C) 1 (Complete in Triplicat 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County PublicHealth Services. Job Address _l Z `J - City E640l Lot Size/Acreage ' Cry) Owner's Name Ai It r Address !1)11 ' I rFl Ih. 5 Phone i Contractor '1q Address Kill License No. _kV--Ds - Phone TYPE OF WELL/PUMP NEW WELL A WELL REPLACEMENT Cl DESTRUCTION ❑ Out of service Well CI PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES 1001 + DISPOSAL FLD. PROP. LINE 1� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s, C) Industrial ❑ Open Bottom fI Manteca Dia. of Well Excavation 11 Dia. of Well Casing f"omestic/Private P Gravel Pack (I Tracy Type of CasingIF Specifications I'1 Public 1 1 Other I I Delta Depth of Grout Seal I Type of Grout A 4 rT f I I Irrigation 1054pprox. DepthEastern Surface Seal Installed by Repair Work Done f] Type of Pump e,��tt H.P. If State Work Done — Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth �►� TYPE OF SEPTIC WORK: NEW INSTALLATION r I REPAIR/ADDITION I I DESTRUCTION I I tNo septic system permitted if public sewer is K available within 200 feet.) (�1 Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms v 1 Character of soil to a depth of 3 feet: /�W'��a//ter tCb�pN_4�th SEPTIC TANK D Type/Mfg acity PA - � tnts PKG. TREATMENT PLT. Cl RMle4*4FIi�sal Distance to nearest: IQFcundation PrpP4rly I�y�e��QQI►_ ON_ LEACHING LINE ❑ No. b Length of lines Total lgald'ICAOUIN W \ FILTER BED CI Distance to nearest: Well Founaation PII r V1;,l�tJ rtVIRUN SEEPAGE PITS 11 Depth __ Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ q 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, al 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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 Call The applicant u call for all required 1 s ctions. C mplate drawing on reverse side. Signed X Title: Valeo Date: FOR DEPARTMENT(%USE ONLY Application Accepted by Date Area / Pit O(G out spection by Date Final Inspection Date Additional Comments: 1" 4�g �y, �n 11 L4 3�.to - S 950-�E'Nv aaf6 Applic�nt - Return all copies to: San Joaquin County Public Health Services q1� 1, Environmental Health Permit/Services y 380 ' 6 e 9.951 2'J17 A3�.(kti C 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT NO. I EO•, EM 1324 illrin 5r I3 � a6 EN 1A 20 V