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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 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 C �`� /✓ City J7� K-7y'� Lot Size/Acreage )i 79 F/ S - c ;vGS rW&C r3ArUCr ti•4cvr 2�L �` Scv .. Phone /!l0' ✓`�! }�j� Owner's Name Address �L�e/O Cip�iirf,rLCe/t-L G-i12� �J/yIs f--- _ �S`YU ConvAtQr 6< C'$ ANGAddress �cl`�c�2� G� License No. U 9S 3 Phone TYPE OF WELL/PUMP: .NEW WELL ❑ WELL REPLACEMENT it DESTRUCTION ❑ Out of Service Well ❑ -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ • , OTHER &7 Monitoring Well ✓J i��_�J�.vc DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. PROP. LINE/5772' FOUNDATION !� AGRICULTURE WELL ' & 'ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' t� cam P1 'l! C-I Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing [1 Domestic/Private ❑ Gravel Pack O Tracy Type of'Casing__ Specifications I'] Public (+YOther 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation i Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. ___ State Work Donp Depth iD Material aterai ep Well Destruction O Well Diameter Sea • FJ✓ `)W e5 1? 1 Depth Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION i I REPAIR/ADDI710N I I DESTRUCTION I I INo septic'system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_'tither. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Metbod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ,Total length/size' FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: 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 peiiormen6e 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 yl shall employ persons subject to workman's compensa- tion laws of California." The applicantt call for all r@quired inspections. Complete drawing on reverse side. Signed X Title: Zf /✓.,�>.��Nc,v��ac �a<<5� Date: FOR DEPARTMENT USE ONLY , Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comtiiints: t! Applicant�r Return all cdpies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMIT- CK TED PEMIT NO. D� e 1 ED CASH RECEIVED BY DATE Rg7 J?C • EH 13-241NEV.I/M 5) L EH 14-2e