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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SE VIA k — I ENVIRONMENTAL HEALTH DIVISION ; i ? j 445 N SAN JOAQUIN, PHONE (209)468342 rC( P O BOX 2009, STOCKTON, CA 952011 ` R PERMIT EXPIRES 1 YEAR FROM DATE ISS (Complete in Triplicate) - `�— F1 Application is hereby made to San Joaquin County for a permit to construct and/or ins lthe--vark-1 in%iiesrr-i�d____Thifi__. application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regula o Joaquin County Public Health Services. r Job Address Cit Lot Size/Acreage P, Owner's Name 9Pa4erw,,a ([Address Phone ! 7g— `Q 73 f Con tracto Address C� �• License No. 2z-17 Phone 69-4 MV TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service We11 ❑ I — PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Ke11 ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS e INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well'Casing i El Domestic/Private ❑ Gravel Pack* ❑ Tracy Type of Casing_ i ns I.1 Public f-7 Other n Delta Depth of Grout Seal YT-�o■o rout I i Irrigation _Approx, Depth I 1 Eastern Surface Seal Installed by RECEIVED-- Repair Work Done 0 Type of Pump H.P. State Work D4r��F 94 Well Destruction ❑ Well Diameter Sealing Material & Depth Y Depth Filler Materialfi Depth SAN JOAQUINES TYPE OF SEPTIC WORK: NEW INSTAL TION REPAIR/ADOITION i I DESTRUCTION I 0feetn sewer is ' t Mo Bi L� f f oM E. ra407-tc_ -r, ;( � le Wit in o0 .l Installation will serve:. RM nce_ Commercial_ titer + Number of living units: Number of s I Character of wit to a depth of 3 leer: Water table depth �j SEPTIC TANK ^ Type/M! Capacity d No. Compartments 42 PKG. TREATMENT PET. ❑ f / Method of Oil Sal I Distance to,nearest: Well -,� - # Foundation. Property Line S` f LEACHING LINE No. fir Length of lines To�al length/size X FILTER BED ❑ Distance to nearest: Well SD2 Foundation Property Line SEEPAGE PITS Depth Size fyuinber SUMPS 0 Distance to nearest: Well 40(2 0't Foundation /0 Property Line DISPOSAL PONDS ❑ + I hereby certify that I have prepared this application and that the work wilt 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: "I certify that in the performance of the work for which this permit is issued, I shall not t`" employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature I I 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- 0 't tion laws of California." l The applicant ' s all for a177K_ ' pecttons. Complete drawing on reverse side.. Signed Title: /. Date: f { .• t FOR DEPARTMENT USE ONLY Application Accepted by Date r Area 117 9 Pit or Grout In" tion by Date Final Inspection by _Date Adt l' ��4Y� S ditional Com n : a Applicant - Return all copies to: San Joaquin County blit Health ces Z (31xy Environmental Health Permit/Services d 445 N San Joaquin, P 0 Box 2009, Stkn, CA 9FEE 5201 ` INFO AMOUNT DUE AMOUNT.REMITTEO SH RECEIVED !DY DATE PERMIT'NO. EH 13-24(REV.1/N 5y 5 1 ((a) EH 14.26 /// 4