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I ' APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL\HEALTH DIVISION 445 N SAN JOAQUl , PHONE (209)468-3420 P 0 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 Han Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address kaw Z k4a, City of Size/Acreage Owner's Name • 'rQ►�+t e#i aS Address T�Q ■ LGIG �Q L&%_Ke!__ Phone t_ Contractor�e' �;±r- `� AAddress © � 1911 I icense No,lb23 13 Phone b' TYPE OF WELL/PUMP: I�; NEW WELL 171 WELL REPLACEMENT. ❑ DESTRUCTION ❑ Out of Service well Cl. i PUMP INSTALLATION {� SYSTEM REPAIR OTHER p Monitoring Fell L7F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE it F,OUNOATION 4 AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 r ✓ INTENDED USE 11TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C-] Industrial ❑ Open Bottom U Manteca Dia. of"Weli Excavation Dia. of Well Casing ' s t7 Domestic/Private C7'Gravel Pack L7 Tracy Type at Casing_ ': Specifications ` V1 Public l=i.Other 0 Delta ,:Depth-oF Grodt Seal Type of Grout r `'i I 1 I Irrigation __ Approx. Depth I I Eastern . !�5 pc' aul Installed by . " ; Repair Work Done Type1. of Pump 3 - »� tH_P�_ , �-•f State Work Done a VWell Destruction ❑ Well Diameter i Sealing Material 8 Depot — DIpth Filler Material i Depth! _ TYPE OF SEPTIC WORK; NEW INSTALLATION 11 REPAIR/ADDITION 1 1 DESTRUCTION I I iNo septic system permitted if public sawar-is i available within,200 feet;) Installation will serve: Residence Commercial__ Other F n' j •/y; .Number of living units: �1lLm Number of bedroom Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O ' Type/Mfg Cap ty. No. Compartments l 1 PKG, TREATMENT PLT. ❑ Method of Disposal l "? Distance to nearest: Well Fou anon Property Line ' f. LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Fou ation Property Line i SEEPAGE PITS I I Depth Size Number i i SUMPS l l .•Distance to nearest: Well Foundation Property Line s DISPOSAL PONDS 0 I hereby certify that I have prepared this application an that the work will be done in accorda a with San Joaquin county ordinances, state laws, and ' rules and regulations of the San Joaquin County Home owner or lic ant's signature certifies the following; "I certify that in the performance of the work for which this permit is iss d, I shall not employ any n in such "nner as to become subject to kman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the Ilowing: "I ce i.:y that in the ormance a ork hich this permit is issued, I shall employ persons subject to workman's compensa- tion laws Califor la." q 1 The appli nt II r all r ui awing on side ted[!/ .Signed X Title: 411 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 1Z Area Pit or Grout inspection by Date. Final Inspection by Date I Additional Comments: I� k Applicant - Returl all copies to: San Joaquin County Public Health Services Il Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 I (REV, INF /aFEEO AMOUNTD t1E AMOUNT REMITTED ASH CK 0 RECEIVED BY DATE PERMIT'NO. Y .II ra A EK 13.2 S! _P �- /�/'f'tH 14-26 L 21-31 ,iM.