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�f tf r; APPLICATION SAN OAQUIN COUNTY PUBLIC HEALTH M VICES PAYMENT ENVIRONMENTAL HEALTH PIECOVED s 445 N SAN.r JOAQUIN ,-:PHONE (209)468-3420 .. ! P O BOX 2009, STOCKTON, CA 95201. . A U 0!0 2-4993 SAN JOAQUIN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HEALTH SERVICES (Complete in Triplicate) ENVIRONMENTAL HEALTH DIVISION R II 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 1662 and the Rules and Regulations of San i Joaquin County Public Health Services. Job AddressQ75 6.R1�Ni -,/UC City dfACC`l Lot Size/Acreage 17 070 S42 F{� 1 y Ge ra yl SP�r!'y G�� Owner's Name e iZ" /`u Address 1� G1'4 t** 61441JOIAZ " :9-T9 f ►'hone >Ona d /.rGK-r j IO&RI 0/jur- Ave T Contractor ue_f 7r c&i Address f'7et.k dg 1,_ I C"A License No.k5Z3 t(o Phone RY 7— TYPE OF WELL/PUMP: NEW WELL ❑ fi WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Hell ❑ 1 PUMP INSTALLATION ❑ SYSTEM, REPAIR ❑ 0THEfi'_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /0`jJ� T+ DISPOSAL FLD. /PROP. LINE .f ,FOUNDATION AGRICULTURE WELL OTHER WELV:�/ PITS/SUMPS r INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom' III Manteca Dia. of Well Excavation Dia: of Well Casing El Domestic/Private ❑ Gravel Pack M Tracy` . Type of Casing_ Specifications I"1 Public Cl Other fl Delta' Depth of Grout Seal Type o1 Grout t # It — Approx• Depth l I Eastern Surface Seal installed by Repair Work Done U Type of Pump t. I H.P. State Work Done Well Destruction ❑ Well Diameter ISI Sealing Material & Depth } Depth f ji Filler Material & Depth II TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAtRIADOITION I I DESTRUCTION i I JNo septic system permitted if public sewer is ' i iN tH available within 200 feet.! Installation will serve: Residence Commercial I. 'Other Number of living units: Number of bedrooms : z}' Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK O Type/Mfg h Capacity No. Compartments M PKG.`TREATMENT PLT. ❑ Method of Disposal p + Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C-1 Distance to nearest: WeI`I Foundation Property Line !i r SEEPAGE PITS 11 Depth size Number l d SUMPS Ll Distance to nearest: Well Foundation Property Line ' 1 DISPOSAL PONDS ❑ I 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 empl6y 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, 1 shall employ persons subject to workman's compensa- tion laws of California." s t� The applicant must call for all required inspections. Complete drawing on reverse side. r 1 y Z igned X Gtr N A Title: Date: FOR DEPARTMENT USE ONLY .1 - . ._ _. 35 01 Application Accepted by `'' Date ' Ara& � Pit or Grout inspection by Date Final Inspection by Date Additional Comments: CLOCIeveirL11 O r i 5 W(Ucledr I j I Applicant - Return x11 copies to: San.Joaquin County Public Health Services.- 0 � �� 4 Environmental Health Permit/Services - ED 445 N San Joaquin, P O Box 2009;" Stkn, CA 95201 2 atIZME2 Lap FEEDUE AMOUNT REMICA AMOUNT TTED ` RECEIVED BY DATE PERMIT NO. INFO CASH . Eli 13-24 iAEV.1/4S) EH 14.26