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APPLICATION SAN 1AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mede,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. � �QAb Ck4 .r OF T-7C City tA�Q•v Lot Size/Acreage Job Address � —I Owner's Name IN AV 54",y" DC*r Address '`�N�r,,,"e0,41) , i L"-' -5^109PPhone�')9-98 X088 Contractor��2E�.s- D/IJWA(G- Address IrppD /y"17N'e L AS License No. �VS16 Phon O-3I3'� TYPE OF WELL/PUMP: NEW WELL Q yltcls WELL REPLACEMENT (sY EDJ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C3 SYSTEM REPAIR ❑ Cf7�10THER B,' .Monitoring Nell ❑ 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 E"rj'If oyCD It'vol Cl Industrial ❑ opn Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Cl Domestic]Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public I:1 Other F Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth 1 I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 810 feat.] Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of and 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 ❑ No. i Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I - Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lim DISPOSAL 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: "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 m�us%hcaglor dl ui a ins tions. Complete drawing w reverse side. Signed x Title:4aKfRJ �CC4 Date: ^/` 7 _ . 0. FOR DEPARTMENT USE ONLY Application Accepted by '�' �G �'L^�'rX Date 2,Z/7'7 y 7 AreaCU� «J Pit or Grout Inspection by Jj-n Date Final Inspection by Date S Additional Commence: /Sl^ - r� /tl W S �2 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services d/ 445 N San.Joaquin, P O Box 2009, Stkn, CA 95201 . I / AMOUNT REMITTED K ' eY DATE PERMIITT NO. I3CNFO AMOUNT DODoge EH 131-24(REV1r.sr 0(2 Y-3 L EH 1 M /Jj z 97