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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH S&VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 = PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDy O (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. \f M ' © Sa Job Address �� l�`t ,r`a-�"��"'"' �p City 1/�C-�- Lot Size/Acreage Owner's Name eC 1 ekv" -� (IMP-q Address TO LO)C 2'U b �C ��P one 707` 7`,�5�6 //�� Q I/ /meq g C.57 Contractor �A" UI Address[• o,a DIC.5 RI o!/sr CA License No. 7/0678 Phone 7 z� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION KOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 0 Industrial ❑ Open Bottom VManteca Dia. of Well Excavation Dia. of Well Casing f-I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1.1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _ 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 a. Sealing Material & Depth IVC A,7T C:�MaW T' 3 o' Depth 3 0 + Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: 'dence_ Commercial_ Other Number of living units: Nu f bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Cap. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Len lines Total length/si FILTER BED ❑ Di a to nearest. Well Foundation Property Line SEEPAGE P 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l 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 for all quired inspections. Complete drawing on reverse side.,e�1 Signed X Title: &jV_AA-_ 101X2 AZZ eA`jV SVCS, Date: FOR EPARTMENT USE ONLY Application Accepted by Date ✓ Are Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services n�n Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 1 -1CASH RECEIVED BY DATE PERMIT'NO. . EH 13.24(REV.rix a) ,(5) b'W EH 14.2a