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ov / / APPLICATION - T SAN kJ AQUIN COUNTY PUBLIC HEALTH . tVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 3 YEAR FROM DATE ISSUED (Complete in Triplicate) Y 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 _ -7001 /li'I!� dud City �f Lot Size/Acreage IO Owner's Name Ran Address3�eL �IC ,ti l/e S ke,�7 1 Phone- -L 9`2 W Fqm It-y u ST Contractor Address License No. St 2.7-G 8 _Phone N6S-00IZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Dril\ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Cp51 n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 211 5oA-gn PUC.. Specifications 11 Public Cl Other 1K Delta Depth of Grout Seal Type of Grout Q I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Dane O Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITICIN .l I DESTRUCTION I l iNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water ttlrrE NT9 SEPTIC TANK ❑ Type/Mf Capacity No. Cola1 MID PKG. TREATMENT PLT.❑ Metho ft fines2 IM Distance to nearest: Well Foundation Property 19' PI to) OUNTY LEACHING LINE ❑ No. &.Length of lines Total lengt FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI 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: '9 certify that in the pewformance of the work for which this permit is issued, I shall not employ any person in such manner as to became subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 campenss• tion laws of California." The apicant ust call for all reguire4 inspections. Complete drawing on reverse side.461 - `- cOt Signed Title: �T/ �► Date: �—Z�O! -- --FOR DXPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by ate v Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKItRECEIVED BY OAT PERMIT'NO. INFO I f CASH Q • EH 1324 MEV.I n 51 1/5 a�� 4f 1 n 0 EM 14.70 «fill \SJ VV