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APPLICATION 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 EXPIRES 1 YEAR FROM 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. pp �-r. ob Address 92 ,91 #zzwPy PO City&4CO LO/./ )Lott SSie/Acreage nn//Owner's NameeJ / / 9kVW e0 S'V�yE� Address 9/9 /�E�/PY /C N n Phone AF6 -� /y( Contractor /7�F /.t/L` f�/rjF-/s + Address D�R�DA[�' CA License No.1�93-7O`; Phone f •S'56 / \TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 Ll Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing r Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications I Public 11 Other f7 Delta Depth of Grout Seal Type of Grout - I I Irrigation _ Approx. Depth 1 I Eastern 5 r ce Seal Installed by Repair Work Done ❑ Type of ump H—P--- S S— tate Wo, "n _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other ^- Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina s LEACHING LINE ❑ No. 6 Length of lines Total length/sire C, FILTER BED O Distance to nearest: Well Foundation Propeny Line SEEPAGE PITS ( I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby cenify 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 workmen's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following: "I 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 Cslit Ia." Theapplican u II or al sa uired inspections. Complete drawing on reverse side. Signed X Title: C.c✓nil Date: -�-'9•f \ (� F DEPARTMENT USE ONLY ' Application Accepted by Aa, L" `- - Date Area Pit or Grout Inspection by Date Final Impac I Date ,L Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services1 {\=,tJ�.,(�/(�\l' 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE i , L y\`1I�1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9y DATE [7�PERMIT NO. ONO • EH t]._Ntl'aEv.m ar 5 tJa �i Vo EH t4M