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; c''` ' APPI,ICATTON FOR P1SR3dIT SAN= OAQUIN COUNTY PUBLIC HEALTH�RVICES w - ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 is ccw, liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San, Joaquin County Public Health Services. Job Address I_Dw5 E. City LATW tZO Lot Size/Acreage `t S33C Owner's Name&ArMCA twIrit D SCH.IALdress S LD4cs6 Ac)C C.A17f/Z� Phone�� $25-3 �l Contractor SP—CpdresC E • �.' SIbCkTiaI&License No. S/.9�12ZIJ? h�ne TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION © SYSTEM REPAIR,[] OTHER;®, Monitoring We115 DISTANCE TO NEAREST: SEPTIC TANK �f_A SEWER LINES }25 DISPOSAL FLD.�_ PROP0 L Ne �p3 FOUNDATION —E-)` AGRICULTURE WELL �_ OTHER WELL L[A PITS/SUMPS ?52) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 C] Industrial ❑ Open Bottom W-Manteca Dia. of Well Excavation Dia. of Well Casing Ye Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ P Ir Specifications F_4 SC Il Pubk V4 Other P40 ii-mCi Delta Depth of Grout Seal _ Type of Grout t I Irrigation :W Approx. Depth `vEastern Surface Seal Installed by S'Q6 6 Repair Work Done L1 Type of Pump H.P. State Work Done s Well Destruction ❑ Well Diameter Sealing Material i Depth Depth hiller Material i Depth .� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence T Commercial— Other Number of living units; Number of bedrooms �`a_._ 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 r LEACHING LINE ❑ No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation .Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 lacus, 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 m I all for all required inspections. Complete drawing on reverse side. q Signed Title: Date: / _---RM-DEP RTMENT USE ONLY rw Application AcceptedC, J) Date `�'�"� AreaIV IF Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services r Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT OtlE AMOUNT REMITTED CK RECEIVED By PATE PERMIT NO. INFO ^CASH . EH14.24 ila-ze IIEV.I/ Ex 01 6f ` J-t}.�- '• `c.��t-' r U' `� 1 `-'�"'L