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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTa—vERVICES 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) Application 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. R,4.TZc S1.. Nom. t Job Address 3�1c VYC}T K,iCity L•Ci:! Lot Size/Acreage _ 94,,-k0 APPi-E _ Owner's Name �tlR�� l Address C"O�kTGf-f CrN'i--0F 411A95Z04 Phone cP) 4IrF- -L3�x i Ierttree4or W A,%--0E:f7 L.iaML.!Address L4=!h1 0CA.1-1m mlA95Z_0 License No.CC I I T Phone(,C!F?) TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 171 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public (-'I Other n 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 ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ' I REPAIR/ADDITION i I ,DESTRUCTION I 1 INo septic system permitted if public sewer is Ms-98-16 FERC.OL_A-Tta ' p r.i -r—=S eQt-11` r - \ ) available within 200 feet.) 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 _P►rAo*MENT LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 11 11 61 1 SEEPAGE PITS 11 Depth Size Number JULSAN OeAtulrq LINT, SUMPS LI Distance to nearest: Well Foundation Property L PUBLIC HEALTH SERVICES DISPOSAL PONDS ❑ hNAL HEALTH DIVISICr, 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: C*yi�- tt-AG il-i.iE-_.=_P Date: FOR DEPARTMENT USE ONLY Application Accepted by Date J�L i f Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ��-� �� r,, Environmental Health Permit/Services 1 I �� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 `7 v- a �, INFO FEE AMOUNT DUE �A.J/MOUNT REMITTED K &T RECEIVED BY DATE PERMIT NO.. +r EM 13.24(REV.1/`15) ��' V` ' ` �, �� \J� .t �-1 .. i�.j /(� Or �✓ EH 14.26 f