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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ) 445 N SAN JOAQUIN, PHONE (209)468-34201 kL�A�I P 0 BOX 2009, STOCKTON, CA 95201 y� Z►�1� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) pplicatlon 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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. n' ' L-� /rtJ�,�- A Y� cit Job Address } � � � � y�^�� Lot Size/Acreage Owner's Name 00/=,,JOU- ,��E�E�� Address _��7- rp G��'�•�rL/5 _t�v Phone 261 116,2-,1%j Contractor - __ Address License No. Phone _ TYPE OF WELL/PU NEW WELL Cl WELL REPLACEMENT n DESTRUCTION Cwt of Service Well ❑ PUMP INSTALLATION 11 SYSTEM REPAIR Ll OTHER ❑ 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 (I Industrial ❑ Open Bottom L-] Manteca Die. of Well Excavation Dia. of Well Casing LI Domestic/Private n Gravel Pack I-) Tracy Type of Casing________ Specifications I'I Public Ia Other I 1 Delta Depth of Grout Seal _ Type of Grout I I Irrigation -_ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. - --- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth v TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sower is available within 200 leet.) 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 ❑ Type/Mfg __ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal \ Distance to nearest: Well Foundation _ Property Line C LEACHING LINE Ll No. 6 Length of lines - _ Total length/size-- FILTER BED 1.1 Distance to nearest. Well Founaabon __ Property Line SEEPAGE PITS 11 Depth __ Size _ ___ Number _ SUMPS LI Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ I hereby certify that I 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 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." T applicant n)pst cell lorll re ed inspecti Complate drawing on reverse side.Khe igned X Title: 0l4,Z 6/E�� Date: 69"f FO@ EPARTMENT USE ONLY / h 7 I I Application Accepted by C�"� c _ Date G Area Pit or Grout Inspection by Date Final Inspection byi_�`L�G y"1 _ lDate7 �• !/3 Additional Comments: .2"AJ �h�n<� /'nS/r fr lDraf a��r 6)1=, '9 1- T/-<, // /,'70 —I • Ll�A,�Y.�z _!t I r j /r/;r?t a AC' I/JrT JC*i Appllrnnt - Return all copies to: Sun Joaquin County Public Heal t}1 SerLic�: ..�f/ l Envlrunrnontal Iioalt:h Pormlt/SurviconS -0•I5 N San Joaquin, 11 O Box 2001), Slkn, CA 05201 !_ice !C FEE .Cyr��!! !: •,'^ �.`� INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT N r9 Er 13 24 inEv,i he / C11- ��, LID i 3,I -twzt 1- c �5 �j j EH 14 26 /