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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES Z YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to Sen 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. Job Address _7-17— �Us7'RY4L f2�t� - _ qty '1bt.jCi*q Lot Size/Acreage _ NLt9- Owner's Name M_.A_,_Q0Q&-ReYK0LbS Address?-17- _X_M_0 zM34t QRzt.0 S?txJ e-Z0ti,Phone S93-0 A 1 Contractor 4gsoe-. Addressl7-34optourc 'f':S rs.rt License N A,r(q!1Q6Phone f TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHERV Monitoring Well CI �!� .S0� � QoRzHG• DISTANCE TO NEAREST: SEPTIC TANK ! — SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 4L -+- AGRICULTURE WELL OTHER WELL PITS/SUMPS 1` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravels�� ❑ Tracy Type of Casing_ t Specifications I'1 Public Other IQO�� fl Delta Depth of Grout Seal _ Type of Grout I I irrigation ZO Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l 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: 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 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to dearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "1 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 applican must =S11d inspections. Complete drawing on reverse side. Signed X Title: L-viG-a t^ Date: 171ATOA91- FOR DEPARTMENT USE ONLY Applicatio cceptad by Date -7 Area D Pit or Grout Inspection by Final Inspection by n.t. Additional Comments ` 1311L7Z� s �+►� r Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 FEE INFO AMOUNT DUE AMOUNT�jREMITTED ASH RECEIVED BY D/ ATE PERMIT'NO. Page 13A EH E17-21It1rv.4/MSI X /)�� f i /rl P 11•2e