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' APPLICATION -- - - — -= _ it � / SAN .xOAQUIN COUNTY PUBLIC HEALTH V S ENVIRONMENTAL HEALTH DIVISI #1 � {� ��9l0 445 N SAN JOAQUIN, PHONE (209)4 8-g /�2 P 0 BOX 2009, STOCKTON, CA 9 2pAC # PERMIT EXPIRES I YEAR FROM DATE I /0 // a (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 Heaalth Services. Job Address 194- 50 � � g City Size/Acreage )� Owner's Name +r dress — Phone UPIf +_ Contractor Address J License NP Phone /10 TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT 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 SPECIFICATION PA r ill Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation "j�C"'ED�l�!!�bI Well Casing 11 Domestic/Private ❑ Gravel Pack L3RE EMETracy Type of Casing_ Otions I'I Public ❑ Other fl Delta Depth of Grout Seal MAY 9fyMM.Grout I I litigation _Approx. Depth I I Eastern Surface Seal Installed by wn WIN ��JJJUN TY Repair Work Done ❑ Type of Pump H.P. Sta�i( r Well Destruction ❑ Well Diameter Sealing Material L Depth ON Depth Filler Material i Depth TYPE OF SEPTIC WORK^ NEW INSTALLATION iff REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower is �� I Installation will serve: Residence L Commercial_ Other available within 200 lae[.1 Number of living units: — Number of bedrooms il�7_ 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 /00+ Foundation :2 0 Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearer: y Well /6 O ^E' Foundation� Property Line�(Z / 7 /d I r L SEEPAGE PITS 11 Depth Sixe /_.z, L _�-- Number SUMPS LI Distance to nearest: Well �Q- Foundation.�.1_ Property Line DISPOSAL PONDS ❑ 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 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 subcontracting 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,pnust call fop pll ulred inspections ,o ete drawing on reverse side. Signed x�/ �( TJ ��Ly�e �_ Title: Data: , (��) �/� FOR"DEPARTMENT USE ONLY Appliys Accepted by -.as �,✓" x L�""u(y'zir� Date `7�1T Area r �� r t Ins tion by� Date Ltd Final Inspection by Additional Comments: ii >2 ZigiJ �i J�,�.x �:/`T�,f��¢i Applicant - Return all copies to: San Joaquin County Public Health Services 1 Environmental Health Permit/Services t _ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFE AMOUNT DUE AMO�UNT REMITTED 'SKR IVED By DATE PERMIT H 'NO. . EN 13-24 IREV.111151 ENuxe 1