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APPLICATION pp }{}► SAN TdAQUIN COUNTY PUBLIC HEALTH V��I'&# ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOA UIN PHONE 209 4 ^- � � P O BOX 2009, STOCKTON, CA 95211 FAC 52 1FAC # - PERMIT EXPIRES 1 YEAR FROM DATE I yy � (Complete in Triplicate) tttt Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. Tkts application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Son Joaquin County PublicHealthServices. �� Job Address 0 1 l .l 1 k)U n !i 131?1 D C },— J^ ,y -( �_ Lot Size/Acreage Owner's Name Ott1`= ,P //LS !-/' /17/ri!Adtlress �'Yt•' go� —?237 /teal Phone3(—R T J n- Contractor Address _/iF__ CCLL.C[) License No. 7 WW Phone TYPE OF WELL/P P: NEW WELL D WELL REPLACEMENT D DESTRUCTION D Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR *l 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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private D Gravel Pack D Tracy Type of Casing_ Specifications 1'I Public (1 Other fI Delta Depth of Grout Seal Type of Grout 17�) 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 dJ Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer iso\ 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: Watp depth Q SEPTIC TANK ❑ Type/Mfg Capacity N d PKG. TREATMENT PLT. ❑ NA1Fa Distance to nearest: Well Foundation Pro eAy! tm P Aro�4� LEACHING LINE ❑ No. d Length of lines To` { (F`x,E'� FILTER BED ❑ Distance to nearest: Well Foundation PropMY �rty+l i�u SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line 1��1 DISPOSAL PONDS ❑ I hereby certify that 1 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 certifies the following: "I certify that in the periormance 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. r '` Signed X_yr - Title: ��.->,//✓�'�iZ(/�,> Date: FOR DEPARTMENT USE ONL�/Y ' Application Accepted by \� • I CI `-'3r^Srltiat� Date S/��A,ma �k p �� Pit or Grout Inspection by Date f� Final Inspections bby.-T�S �� ---, Data L Jef'i/�1 Additional Comments: �.� /7 1r1sIp J -,ft �-gcJ2-G r)-�/Aim �� Qye-r, ¢%"�7 Applicarjl - Return all copies to: San Joaqul�9.V Pub116 Health Se�� " v / a CA \ Environmental Health Permit/Services \7�-TfJ 995 N San Joaquin, P O Box 2009, Stkn, CA 95201. lam• INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DDA�q�lfTE /' PERMIT- -y 14S EH U.S4(REV,v x st T( ��tt^�/� I �� EH 14aI 1 �, f/� �{