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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 {PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sa)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. / 4girc Job Address Ca/QJ7JLY ' nyx gon - City Lot Size/Acreage G Owner s Name C0 Address - l 3 A'L i IV C Phone Contractor fLfigo 1!l!�- IV Address License No. Phone � - r TYPE OF WELL/PUMP: NEW WELL St WELL REPLACEMENT Cl DESTRUCTION ❑ out of service well D PUMP INSTALLATION ❑ SYSTE�M� /R�EPAIR ❑ oO�THER ❑ Monitoring Well 'ter DISTANCE TO NEAREST: SEPTIC TANK 106 SEWER LINES AJ/A DISPOSAL FLD. PROP. LINE ,_ _� FOUNDATION �� M AGRICULTURE WELL OTHER WELL � PITS/SUMPS IA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing �� vy 1.1 Domestic/Private ❑ Gravel Pack 1KTracy Type of Casing___4 __ Specifications 3 6 ['I Public f-I Other i I l Delta Depth of Grout Seal 3 /IT '201jetno4ype of Grout_FMCAfr - - v" I I Irrigation 3.6fApprox. Depth l I Eastern Surface Seal Installed by rFie ca&/ ~ Repair Work Done 0 Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter 2 r -- Sealing Material & Depth 5_f jC E) C%g2 k �'L AAJ _. Depth f Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1.I REPAIRIADOITiON I ) DESTRUCTION I I (No septic system permitted if public sewer is 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:i Water table depth t� SEPTIC TANK. ❑ Type/MfgJ Capacity No. Compartments E 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 PITS 11 Depth F Size Number SUMPS Ll Distance to nearest: Well Foundation . Property Line DISPOSAL PONDS ❑ 1 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 foIt wing: "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 C ifornia." Theapplica st call for atl uired ins tions p ete drawing'on r e side. { Signed X r Title: w Date: I& — L FOR DEPARTMENT USE ONLY ; Application Accepted by _ ` - ---- Date aZc� f�]-3 Area ::�-2 Pit or Grout Inspection by Date Final inspection by Date Additional Comments: ,} �n Applicant - Return all copies to: San Joaquin County Public Health Services P Environmental Health Permit/Services I 445 N San Joaquin, .P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE x AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO 7 (,,g/ 7 J�� ^-CASH ///}}] . EK 1311[REV.r/xSY ' / f / U _�� 3-�3 q�� EN 14-Zit