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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 Q 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. �+ r f1f Q �1 i Job Address COKYQI H0llr=ul l` =` �KHVP Rc1;C Ow r) Cary rt -lcq Lot Size/Acreage /V1 r. JqTi"k Grrpl:aleS �2FJ Z QinaII Lanz q/ / !� / I Owner's Name ru Ile,- J T 7T1 z y �r�1d C NSTin, Address r%thr�f C`" ..4 /s O/ Phone y/C r �l X352 z- P, v, Cox 1 b 6`l �1 / Contractor YY 25 �'�x Address 111,1ef 74Gra/0,Iti,710 GST License No. ��L Phon �� _V, ///l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7 DESTRUCTION a Out of Service Well ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER Monitoring Well U 56-I '—d- _S43-2 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �+ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing_ Specifications I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done L3 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth i L TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other (j Number of living units: Number of bedrooms C Character of soil 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 C1 No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line IC SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 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 f r I require inspections. Complete drawing on reverse side. Signed Title: bene 1�Q! t2 e/' Date: FOR DEPARTMENT USE ONLY Application Accepted by , Date I ?� Area Pit or Grout Inspection by Date ^ ZFinal Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services S� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009 Stkn, CA 95201 FEE il� INFO AMOUNT DUE AMOUNT REMITTED C K R ED By )�/DA�/TE PPEERM17 NO. EM 13.24(REV.I/A5) f/}./ (/'� V�.� �� -12- 2 EM 11.76