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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 C)i�5 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 coulpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ': a8/y fie/ d/� Lot Size/Acre e ��' Ciry Lam_-^ �//J t,'/�Io Owner's Name _j/1/ / Q M ae lGrDDTAddress 71-3 " 'vim^ A—) Phone Contractor./yiii.1s Address ;7— _5 /1 License No. Phone . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 141 OTHER O Monitoring Well O 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 fl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` 11 Domestic/Private O Gravel Pack ❑ Tracy Type of CasingSpecifications I'1 Public Cl Other fl Delta Depth of Grout Seal _ Type of Grout , Ixlrrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump r,..,rL. ,V H.P. -!�_e State Work Done C e- vE� Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 r -DESTRUCTION I I (No septic system permitted it public sewer is available within 200 lest.) Installation will serve: Residence _ Commercial _, Other Number of living units: Number of bedrooms ��rNT Character of soil to a depth of 3 feet: �� JA SEPTIC TANK O Type/Mfg Capacity PKG. TREATMENT PLT. O � 8141is> Distance to nearest: Well Foundation Propen insTy AN JOA NIC LEACHING LINE Cl No. b Length of lines Total lerpli �TIH DIVISION FILTER BED 0 Distance to nearest: Well Foundation E� perty Line SEEPAGE PITS ( I Depth Size Number SUMPS 1.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 Sen 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 shalt not employ any person in such manner as to become subject to workmen'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 st s11 for'All requir i ctions. Complete drawing on reverse side. �Mi.� Signed X Title: See-.,- 't-n-7 r":F! �r Data: 2-3- 9'--7 T US LY Application Accepted by Z EPARTM Date roe a n Pit or Grout Inspection by Date Final Inspection b Det Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Per /Services 445 N San Joaquin, ,Bo 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOU T REMITTED K I RECEI ED BY QAT PERMIT NO. EN t)-24 111EV.i i n 51 INFO ' FN t4n