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APPLICATION c -.11111WJ eq,- Wet kr)4,\ SAN JOAQUIN COUNTY PUBLIC ENVIRONMENTAL HEALTH IN P. WMENT— It 0. j 2 3 l J43 445 N SAN JOAQUIN, PHONE 20 4 8-3 4 0 P O BOX 2009, STOCKTON, MD#201 RECEIVED PERMIT EXPIRES 1 YEAR FRoN uAnkissuID F `' 9 2 2 1C_4 (Complete in Tripl i catse C . ,NT Application is hereby made to San Joaquin County for a permit to construc a4 1) n }!R@ jM �AG. Tt rkVjf. 5 trqsu application is made in coatpliance with San Joaquin County Ordinance No. 5 u es and Regulations of San Joaquin County Public Health Services. /� Job Address t/. c . 1 (lam AwnlA e- City 1 Lot Size/Acreage V0 42 �17' 6L, / - 1.• /—i Owner's Name JA 4- �`M 5` �- Address �� .R kQ�ti9 vrQ. ��1� - Phonei31G� �CZ3-gb�lu Contractor T I/V 1 Address (�ci„ p Cr- r� �� License No. 5`�'{t�1 Phon ( L TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ THER ❑ Monitoring Well Ar IOf DISTANCE TO NEAREST: SEPTIC TANK Z SEWER LINES '50 r DISPOSAL FLO. N I ft PROP. LINE I t5 r FOUNDATION 1 AGRICULTURE WELL OTHER WELL_( PITS/SUMPS Ate} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l2 L rr pe Dia. of Well Casing 17-1 Domestic/Private Gravel Pack ❑ Tracy Type of Casing_,_Pvc Specifications Sc3,,cA `fa I"1 Public (-I Other F1 Delta Depth of Grout Seal ZO { Aot%A Type of Grout A Cf' I I Irrigation �Approx. Depth 11 Eastern Surface Seel Installed byW-'st + rcnci� -pr A" Repair Work Done ❑ Type of Pump rf H.P. State`Work Done _ W Destr trio Well Diameter Z. Sealing Material t Depth f1 :C.r- - X Lr W �� Filler Material i De X4 s1aw G 7 Depth �� NCS p wtrev�r� GGu�IE�CI I �Or TYPE F 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.I v Installation will serve Residence _ Commercial Other _ Number of living units: Number of bedrooms _ 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 LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS l_I 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 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 allrequiredinspections. Complete drawing on reverse side. �(� Signed X Y � t�—�V�]�Cx Title: � % �� Ilif na r Date FOR DEPARTMENT USE ONLY Application Accepted by 94 _ Date CCS u Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 3 y W + �� Applicant - Return all copies 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 REMITTED CK H RECEIVED BY DATE PERMIT NO. 350/ EM I)24(REV 1-5), �vZ� • OD(/3 L� EH 1 3 20 666