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APPLICATION rr 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) ppllcatioa In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This ppllcatlon In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San oaquin County Publio.-Health Services. / �� /�� / Ib Address 76//l /J,�,/.�,��!Tpn�dl /ed, -7 C/ity�/yllyck//r/Q_, Lot(�S�ize//Acreage '/,,Z� l(-(. J J Hner's Name (&I(t 6fit)L�-�a J Address /64/7 a) H/�LCJ(�a .0/�. ��,lYAtx/axoao 43 -&IOZ.4/ ontractor lOS. Address - ,/Q U° License No. ZI0113 Phone J�/� ✓' (PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION gout of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ STANCE TO NEAREST: SEPTIC TANK /DA SEWER LINES DISPOSAL FLO. 1JV PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL .ZS t PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation J7" Dia. of Well Casing Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ VC, Specifications Public ❑ Other (l Dellia Depth of Grout Seal Type of Grout 1irA fl+ztt L�r Irrigation _Approx. Depth I I Eastern Surface Seal Installed ht ,pair Work Done ❑ Type of Pump �_ N.P. State Work Done _ ell Destruction DQ Well Diameter _�— Sealing Material i Depth Depth �� Filler Material i Depth \I 'PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permilted N public sewer is �( available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number o1 living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ` 1� PTIC TANK 0 Type/Mfg Capacity No. Compartments .G. TREATMENT PLT. ❑ Methortl q� Disposal Distance to nearest: Well Foundation Property Lini1Y ACHING LINE Cl No. 8 Length of lines Total length/size ! fy .TER BED 0 Distance to nearest: Well Foundation Property in, W2 � r�1�7+tfll EPAGE PITS 11 Depth Size Number, IMPS LI Distance to nearest. Well Foundation Property Line SPOSAL PONDS ❑ ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and as and regulations of the San Joaquin County �me 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 ploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature lifies 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- n laws of Calif rnla." Is applicant at call for all require spections. Complete drawing o reverse d . Ined X Date: �Z, �i�/�/TJ ��'LMT•FOR DEPART ENT E ONLY A/`�� plication Accepted by Date 1 Area or Grout Inspection by Date Final Inspection by P Data Z ditional Comments: T�'T71-h uJ'%�.-�c1�N �t.T`-'.3D qry�, — aar u.Ypy 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 Q-/�OvJGb(�+_ S 'E, C,)C S ON/ wo INF AMOUNT DUE Mc'{O/.UHT REMITTED CASSE RECEIVED BY DATE [�P�E7RMI7'NO. ) i 91Do