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` APPLICATION / SAN JOAQUIN COUNTY PUBLIC HEALTH SE C ENVIRONMENTAL HEALTH DIVISION, }µj �1� 445 N SAN JOAQUIN, PHONE (209)468— 4EG l j6 T (() P O BOX 2009, STOCKTON, CA 95201 i� PERMIT EXPIRES 1 YEAR FROM DATE IS 1 (Complete in Triplicate) L� 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 Public Health Services. .,..,.�p Job Address �e-Tu?— City_n Ats'jl Lot Size/Acreage r 49AC- Owner's Name TjAddress �U V-2'DX ZJ3 'Z� Phone ,1 Contractor J�. "�R'E-- Address 2�7 G- �' ��'it.\ 1. License No. Phone s 'i r 7i7 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ _Mlll L„'�;f-j, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well Ll DISTANCE TO NEA EST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS p` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3 --5 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �'J fl Domestic/Private ❑ Gravel Pack D Tracy Type of Casing___ Specifications �.i I'I Public I.1 Other I l Delta Depth of Grout Seal Type of Grout - Q I I Irrigation _ Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U of Pump H.P. ___ Stats Wj*-Done _ Well Destruction ❑ Well mater Sealing Material a Depth Depth Filler Material a K TYPE OF SEPTIC WORK. NEW INSTA TION I I REPAIR/ADDITIO DESTRUCTION I I INo septic system permitted if public sewer is available within 200 leef.l Installation will serve: Residence _ Commercal ___O1 W ------ Number ___ ' V Number of living units: _ Number of bsdroop _� Character of soil to a depth of 3 feet: % Water table depth SEPTIC TANK 0 Type/Mf Capacity No. Compartments !\l PKG. TREATMENT PLT. ❑ �`� Method of Disposal v /Distance 1 rest: Well F0nQetion Property Line LEACHING LINE No. d Length of lines -Total length /size FILTER BED ❑ Distance to nearest: Well _ Foundation 'Properly Line SEEP E PITS 11 Depth Size Number MPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ 1 hereby certify that 1 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: "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 sub-contracting signature candies 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 California." The applicant Gmust call for all required inspections. Complete drawing on reverse side. f Signed X t' �_ �. --.,.;"—S - Tide: T7s( T,3` t�JF:�^i:.�wP...,. Date: FOR DEPARTMENT USE ONLY Application Accepted by 43 Date _ O Anmi Pit or Grout Inspection by Date Final napecti n by Data ` r+ Additional Comments: Applicant - Return all copies to: San Joaquin Cou ty Public He lth Sery ces 0 � Environmental Health Permit/Services �/1 V 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE�I D INO OUAMOUNT REMIT C RECEIVED By J DATE PERMIT'NO. EMt1NlnEv /xrVb /NTJEM .]a � 06Iq efI