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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 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 Health Services. SSS /QVI Cty 5ror <re Lot Size/Acreage Job Address e / Il 1Y 5-r / --1 /sGo�T po*o.t s. W. ST Jri O�N /3 re one aZat; a7 S/ a 6 8 Owner's Name l �c' N'p�� AAddress Ife')76 4, k/A q g S c/ Contractor �W �r �� -� Address ro. o r• cense No.GS7"7�90/Phon 707 37 �8� TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION t of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O `/0W 7 OTHER O Monitoring Well O DISTANCE T — T: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTE E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation /O 1,ie-4 Dia. of Well Casing N Domestic/Private ❑ Gravel Pack O Tracy Type of Casing__j�a F- Y9 Specifications Depth of Grout Seal oZ 4-e 7"" Type of Grout I.1 Public (-I Other fl Delta �J ,t e- ti I 1 ImUauon _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work 9one _ Well Destruction � Well Diameter 41/ i _ �G Sealing Material i Deptj?_ �P1T e-+ro ti ire f 07GaT Ce-o" � >< � Depth c-3 � Filler Material i Depthia- 04, �e�7- 54•+� ��2 SGG TYPE OF SEPTIC WO EW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if pubic sewer is /N/ available within 200 feet.) oft7`4YL�Ai Installation will rve a ence _ Commercial _ Other Number of living un1 s: Number of bedrooms Character of coil 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 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITSriS) I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL P ❑ 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 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 ing on reverse side. �/� /J Sign ed X r Tor �CG7T �I�a�oTrtle: LT!� !2 14119'' �n 9 Date FOR DEPARTMENT USE ONLY Application Accepted by p Pit or Grout Inspection by f Date Area ` 0 rhe e Final Inspection by Date / h � Additional Comments: L e Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 _17 -G'Y IFEE NFO AMOUNT DUE AMOUNT R EMITTED �CASHHRECEIVED BY / DATE / PERMIT NO. EH 11-241REV.lin 51 /r�6 EH 1 1.25