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APPLICATION SAN 1AQUIN COUNTY PUBLIC HEALT]:1-RVICES ENVIRONMENTAL HEALTH DIVTSION 445 N SAN JOAQUIN, PHONE (209)468-3420 MAY0 P O BOX 2009, STOCgTON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR- FEN DATE ISSUED (Complete In Triplicate) PERM ITISERVI CES 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 Joaquin County public Health Services (' � Jab Address _L_=r I 1 /'_I`/nl(1__1�� Y Ciiy _) 7QC/:TOA1— Lot Size/Acreage r Owner Name A—LLAAEb /71-Q,,6 Fl- _ Add,ess 1 (-Iizrm tA.{' �fi, J- 3LK 7Cn/ Phone Contractor ]�r 1_) C X /Cl,><71C-J J C�b�CA dress C'+ 17 C, f z l License No 5926 Phane J 5�N - TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n _DES:UWCTION.-0 O t of service Well ❑ PUMP INSTALLATION O SYSTEM! REPAIR 0 $CL HER� ) Monitoring Well ❑ DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPO it-f4.0- 4 — PREP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 industrial ❑ Open Bottom ❑ Manteca Dia ofeek Excavation !-VC-ii Die of Well Casingtj ^/ I-) DomesuelPrivate ❑ Gravel Pack ❑ Trac F assn Tracy T ype of acing_ rZA Specifications 4 I I Public I 1 Other n Delta Depth of Grout Seal 1 0��,�(� Type of GrouI/Vr.47' C C.✓ I I Irrigation Approx Depth I I Eastern Surface Saul Installed by Sd LA -A LCr" ,,IJC'VICC.s .Z"t Repair Work Done U Type of Pump — 4/4 H P __ 7 State Work Done r _ Well Destruction O Well Diameter �_ Sealing Haterlal A Depth C-r 'Q IT '� a' 7c $-O'&rjS Depth "r Sn /•T Filler Material i Depth ^/ /A i TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public Bawer is available within 200 feet I Installation will serve Residence_ Commercial— Other Number of living units Number of bedrooms Character of Loll to a depth of 3 feet Water table depth SEPTIC TANK O Type/Mfg Capacity No Companments _ PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Propeny Line LEACHING LINE 0 No b Length of lines Total length/size FILTER BED ❑ Distance to nearest Wall Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Lt Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ t• I hereby csrlify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats taws, and I rule i and regulations of the San Joaquin County Home owner or licensed agent s aignsturs condies the !allowing '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 a compensation laws of California Contractor s hiring or is 5-contracting signature csnifres the following I certify that on the performance of the work for which this permit to issued I shall employ persons subject to workman L compensa tion laws of Call ornla " t The applicant must call for all required inspections Complete drawing on reverse side ,_ Signed —�y ; Tom) Tills ,-'fjCc/Ar-C- CiCCLCej/JT Dat. FOR DEPARTMENT USE ONLY ARplrcatlon Accepted by Date 2 � Area Pit or Grout Inspection by Date Final Inspection by Date additional Comments 1 Applicant - Return all copies to San Joaquin County Public Health Services Environmental Health Permit/Services 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 _ INFO AMOUNT �DLIE AMOUNT�yREMITTED (:ASH RECEIVED BY / DATE �j PERMIT No . fM i}711NtV ir�fi ! 1 -L5751 2.1 � ]� Z6 y/'✓ l'if1 f ►'LJ