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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL, HEALTH DIVISION 1 /4 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROG DATE ISSUED (Complete in Triplicate) opy A}plication is hereby made to San Joaquin County for a permit to construct end/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. JobAddress Of" rY1 _ r I /� City�!J� 1� Lot Size/Acreage Owner's Name -Cell&Ar l O� " Address -Q 3 6 !!!oe1 hQ_ �Z ' PhoneConlraclor-J4) 0lAd6C6kt/ 0" - #2� Address a /Alh G 1JC `f A—License No. )' 6 _ /QPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [.1 DESTRUCTION Ll Out of Service well l=1 PUMP INSTALLATION p SYSTEM REPAIR C1 OTHER jL Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. GFe fE' "� ties gq�ia+t C7 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Encavation 11 — Dia.-of Well Casing fl Domestic/Private C1 Gravel Pack ❑ Tracy .Type of Casing_ Specifications i'1 Public 1-1 Other (-1 Delta Depth of Grout Seal �--8! __ Type of Grovt I 1 Initiation S2,1 CkLz I— _.Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done P - Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material & Depth. TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is Installation will serve: Residence.� Commercial,� Otllar available within 200 feel.) Number of living units: Number of bedrooms 0 Character of&oil to a depth of 3 test: Water table depth SEPTIC TANK p T i ype/Mfg Capacity Na. Compartments , PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 1:1 Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I hove 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 cenifies 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." The applicant Raj 31 call for of uired Inspections. Complete drawing on reverse side. Signed Or Plz� 7G Title: , Date: ? FPR 91PARTMENT USE ONLY Application Accepted by 61 1 � 3 I?/S Rate Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaguin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERM11 N0. • EH 14.E(REV.1/n51 �� t O d - " 3 !.3 4 I