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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1, hereby Made to San Joaquin County for a permit to construct and/or Install the work herein described. This application ie made In coglliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. Job Address __ 4T /'�E\\ LV��S� ITI L.1 O�Cny Lot $lte/Acreage T (Z'-l� Owner's Name Ito% � COOK SCV-) Address 111tS� 1 (= LSU 1'� �L) C Phone Contractor \ Address 2).7ZS �c�oa.v��c License No. 2`i Cffi\� Phone TYPE OF WELL/PUMP: NEW WELL g] WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industnal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation VI c Dia. of Well Casing 61 Domestic/Private (A Gravel Pack7 ❑ Tracy Type o1 Casing_C�k4s'O YU <- Specifications ' I'I Public fl Other �/�/ fl Delta Depth of Grout Seal 1 D O _ Type of Grout u, I I Irngabon -L40-flpprox. Depth I I Eastern Surface Seal Insulted by \ Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter (,.' Seeding Material A Depth f Depth Filler Material L Depth ll TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is X1.1 available within 20D feat.] Instillation will ssrvc Residence — Commercial_ Other _ t� Number of living units: _ Number of bedrooms , *) Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest, Well Foundation Property Line LEACHING LINE D No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founaahon Property Line SEEPAGE PITS 11 Depth _ Sire Number SUMPS LI Distance to nearest Well Foundation Property Lire DISPOSAL PONDS ❑ I hereby cenRy that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, nate laws, and rules and regulations of the San Joaquin County Home owner w licensed agent's signature certifies the following: 1 certity 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',hiring or sub-conmacting signature certifies the following:1 certify,that in the performenca of the work for which this permit is issued, I shall employ person,subject to workmen's comp i tion awe o1 California." The apphc Tit must can for W req iced inspeoliona. Complete drawing on revepe side. Signed �n�_�- 131L] L\� Tide: � k�,L�� Date: r^�A- �-, DD FOR DEPARTMENT USE ONLY / Appliutbn Accepted Dv !Y\.la--t _ Date r a3 _ �N Ars. C21a *44 Pa ol/Orspaciion by Oat@/,L Final Inspection by Date Additional ////DriComments: Applicant - Return all copies to: Be. Joaquin County Pu1,11c Health Servlceis Rnvlronmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 9520 FFa L AMOUNT ODE AMOUNT REMITTED a RECEIVED BY DATE PERMIT NO. fM1}21 URFVLvna� FN a as