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APPLICATION FOR PBRIaIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION u� 1 X993 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 r= ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED = PERMIT/SERVICES (Complete in Triplicate) Application is hereby, made to San Joaquin County for a permit to construct and/or insta.ul the work herein described. This application is made in caApliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health �S//ervices. Job Address /o! of K„77>I e M L L, e City �,a�r Got Size/Acreage - 114 � r r r Owner's Name 0 1/•M`• �a r Address �T r 7/ - rf ��r_ `ter �� Phone{Z°r/�-?Z a 241 J ?7t1 llz;e.,/-{ ir'./. �,/. Z r. Z.c Contractor'1"`P”' 11�4fr /.A r /~r . •Address ��"�� 6--Ora✓, C� 7rL 2- License No. 4 o 2"7 7-" Phone&05Z - ;4S TYPE OF WELL/PUMP: NEW WELL J2 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well 19 DISTANCE TO NEAREST: SEPTIC TANK '12 {4 SEWER LINES 15-2 E DISPOSAL FLO.'ro {f PROP. LINE fin' ro 14 FOUNDATION?°`r"' F AGRICULTURE WELL fir° {� OTHER WELL{.-'—'-64 PITS/SUMPS '!o A4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Sonom ❑ Manteca Dia. of Well Excavation /a — Dia. of Wali Casing 4 'k f.] Domestic/Privets $ Gravel Pack ❑ Tracy Type of Casing f�L 4° 04 5pecilicatians r, I'1 Public 177 Other Cl Delta Depth of Grout Seal 44 H _ Type of Grout`f e,�' I I Irrigation 4S-I�Approx. Depth I 1 Eastern Surface Seal installed byTw..•- &.,)4,—)—.r Repair Worst Done U Type of Pump H.P. Stats Work Done_ Weil Destruction ❑ Wait Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet) installation will serve: Residence_ Commercial_ Other Number of thing units: Number of bedrooms Character of will 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 Cl No. 3 Length of tinea Total lengthisize FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS ❑ I hereby cenify 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(Mowing:"I unify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compenss- tion laws of California." 1. The applicant ttymlust call four+all required insimlions. Complete drawing on reverse side. Signed X / Title: �� s r 7 _ Date: $/ FOR DEPARTMENT USE ONLY Application Accepted by ZC.��9J�.Lr :. - Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 4 Applicant - Return all copies to: San Joaquin County .is Health Services Environmental Health rmit/Services [ g■ �a' 445 N San Joaquin, P O Box 2009, Stkn, CA 95261 ` F tF 0 AMOUNT DUE -AMOUNT REMITTED CASH Cy J RECEIVED BY " "'DATE '" PERMIT•NO. IN 13-24 tREY.1/9,31 �r�= -� Z S/�J .... .� Ek 14>♦