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APPLICATION �p p /J ' SAN JOAWUIN COUNTY PUBLIC HEALTH EB�IAES— ENVIRONMENTAL HEALTH D1 HI 445 N SAN JOAQUIN, PHONE (2 39 # P O BOX 2009, STOCKTON, CA 9 67th # �d PERMIT EXPIRES 1 E D rA1. t (Complete in Triplicate) aP9 J&":2 Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in aide in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San n Joaquin County Public Health Services. cc �•7 ' Jab Address z-� S E , j.}m RDGCI _ cn L1h eE Lot Slze/Acreage C.O it C g C Owner's Name �`r j C�1 ��Y1 fir+ Address ��r1 e - PNone �] ��)� Conhaetor 1'1 dY�n Pua"� Address,�lt Ere License No.��G $Si Phone 47,6 TYPE OF WELLIPUMP. NEW WELL WELL REPLACEMENT Cl OESTPUCTION O Out of Bervlce Voll ❑ PUMP INSTALLATION• -_ SYSTEM REPAIR 0 OTHER ❑ monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. oin PROP. LINE ILD' D' FOUNDATION AGRICULTURE WELL OTHER '✓VELE PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF';CATIONS S- ❑ Industrial ❑ Open Bottom C1 Manteca Die. of Well Excavation. Dia. of Well Casing 4-Domesvd/Private ,$ Gravel Pack ❑ Tracy Type of Casing_. C I Specifications I'I Public' '�11,�),,iAOther P Delta Depth of Grout Seal _I Type of Grout I I Irrigation .73L Approx. Depth I I Eastern lSurface Saul Installed by (3c' ) Repair Work Done Type of Pump S4 bin H.P. r h __ State Work Done Well Destruction ❑ Well Diameter Sealinegy Nate YEa3 Depth - Depth F Ir • Depth , ' TYPE OF SEPTIC WORK; NEW INSTALLATION r I REPAIR N I f STRUCTION t f (No apex system paririrtad it pubec server is YPLL � � ,�p ES available within 2W Peat.) " Instatlation will serve: Residence , Commaircial_ 0��1"`T'S`T- r Number o4 living units: , Number or bedrooms Character of soil to a depth of 3 feet:. S kJ �I-�F� �I - ��ti IJ�J Water table depth SEPTIC TANK ❑ Type/Mfg QL Lr. apaCiry No. Compartments ' PKG. TREATMENT PLT.❑ aMethod of Disposal Distance to neerese Well Foundation LEACHING LINE ❑ No. 6 Length of lines Tcal Ian thf in - ' r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PIT$ I I Depth Sire NLfmbat•,i !G SUMPS r LI Oistanee ea nearest: Weft Foundation uy NLePFupwry itlrli V ' DISPOSAL PONDS ❑ I heraby certify that I have prepared INS application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and reguiationa of the San Joaquin County Home owner or licensed agent's signature 0/911111168 the following: "I certify that in the performance of the work for which this permit is issued.I shalt not employ any person in such manner as to become subject to workman's compensation lawn 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 person Subject to workmsn's companies- Pion law@ of CIf .' The app2tn It call for all required inspe tions. Complete or ing on reverser slide, ' Signed Title: 1111-"CLI Data. , OR DEPARTMENT USE ONLY �/ Applicatlon Accepted by Dais i ,I Pet o mut)Inspection by a �Date S Final Inspection by — Data Additional Comments: Applicant - Return all copio to: 3SeXaeuluin County Public health Services 'f3�b.. &78�-ZA7LJ,RS 0 / fA/ Environmental Health Permit/Services �}3pnt �=N�° 1s�� //Q •�a/)tO 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ' �r 1 10 i L 7"E,J rP� E I AMOUNT OPE /AM�jO�UN/T/, RCE�M/IT'TED I;a CEIVEO 9y AT - _ PERMIT NO. � 'l EHIaNIREv.i�xa L/rim/ /.^'r"Y!/' 1-1 l/ 1///15-6 21 ��/ -7-P�