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APPLICATION SAY JOAQUIN COUNTY PUBLIC HEAT IYSERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application In hereby sada to San Joaquin County for a permit to construct and/or install a {{,, k Brei/ry�,' ®® This application is made in compliance with Sen Joaquin County Ordinance No. 549 and 1862 and t Ed R,ror lrOn of San Joaquin County Public Health e"ices. ^(�' �� r ^ ��,��, LLLLLL...... L. {{{�� eB Job Address 46662 1 �1� {�CCny fib_ s�aa-� Lot Size/Acreage Owner's Name = l I.r\_ W L Address___� 4- 0 Lpaw JCiIq�.•./IVPhone Contract - Address License No ,JaPho TYPE OF WELL/PUMP:e NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public fl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION INo septic system permitted if public sewer is J available within 200 feet.) Installation will serve: Residence� Commercial_ Other ,y ^ QwSr� .fi'7NK Number of living units: __J_ Number of bedrooms Character of moil) too a depth of 3 feet: r^LA�� Water table depth SEPTIC TAW404 % Type/Mfg c L Capacity _ No. Compartments r PKG. TREATMENT PLT. ❑ �. Method of Disposal / Distance to nearest: Well Foundation�_ Property Line r LEACHING LINE FSf/'-�Cl No. 9 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 7 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I 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 flaws 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 California." The applicant s for all require in ions.,C Im a drawing on reverse side. C , �!� Signed Title: �e Date:�� L • TMENT USE ONLY _ IN,A Z- ��- Application Accepted by4Date Area Pit or Grout Inspection by Data L/. � Final Inspection by o Date Additional Comments: �y>"r�(l Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. . EH 1}24(REV.v e w V O Ct7117 b /6�9�2- 9L— .xs y EH 1x-b