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1 APPLICATION S JOAQUIN COUNTY PUBLIC HEALTHOERVICES ENVIRONMENTAL HEALTH DIVISION 30L( �(�Q�6( PHONE (209)468-3420 P O 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 in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin County/ go/ Health ServJiccee/s. Job Address /7 o/ S //�G �Y4l le- City L Lot Size/Acreage 11 � Fra aG' Owner's Namz'�Add,,,, Phone ; / Contractor.f).22Ii_Or Ad s / L/✓!9T/K License No.67304 Phode �� - 2-11 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ 4 PUMP INSTALLATION ❑ SYSTEINA REPAIR ❑ OTHER Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION LYL1L_ AGRICULTURE WELL OTHER WELL 11�1L PITS/SUM � PS f / YL INTENDED USE TYPE OF WfrLL PROBLEM AREA CONSTRUCTION SPECIFICATION '�. �, Q PJ r2 ❑ Industrial ❑ Open B f m ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑.Tracy Type of Casing /7 Specifications _� 1'1 PublicA L7 01her n Delta Depth of Grout Seal // ,„, Type of Groyt B Irri ation _.Approx. Depth II Eastern Surface Seal Installed by , ✓L? I ! air Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW TALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I 1 (No septic system permitted it public sewer is available within 200 feet.) Installation will some: idence_ Commercial_ Other Number of living a: _ Number of bedrooms } Character of to a depth of 3 feet: Water table depth SEPTIC TA ❑ Type/Mfg Capacity No. Compartments PKG. T ATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LIN ❑ No. & Length of lines Total length/size FILTER B ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITSI I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOS PONDS ❑ I hereby certify that 1 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." , I The applica/nm,ust call/for/)/•I require ms ns. Complete drawing on raver/.d Signed)F��`�- /+_,1.�\� Title: Date: ,`'a FO DEPARTMENT USE ONLY Application Accepted by �q' ' ` .Date t 1 Area Y Pit or Grout Inspection by I��rC - Date 6 Final Inspection by Date I Additional Comments: K ✓�-�amQ'f�9--�IYI.c�4tdyJ.rt�lX� ;Applicant - Return all copies to: San Joaquin County Public Health Servi" ces v Environmental Health Permit/Services 445 N San Joaquin, P O-Box 2009, Stkn, CA 95201 FEE gMOUNT DUE AMOUNT REMITTED CASH CK If RECEIVED By DATE PERMIT NO. INFO EH a.24 MEV.r/nmt I. L[7-3,51 —_7y . p / 6�� EH/42a {