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APPLICATION SAN JO QUIN COUNTY PUBLIC HEALTHERVICES ENVIRONMENNTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERI[I T 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 vork herein described. This application is aside in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Cf,�(�,(�, � " / Sp �V` �• City �"�-+"r"1" Lot Size/Acreage �FOOtOX.- �DO (0/ Job Address kt S ,, / f" Owner's Name u S2rUfCeS F�GIt(�'t Address 14�L" 641. 674, C.F Phone Y15.5�'�.3 74� Contractor M T l Qn Address P'D' =< h,Co► a License No olLV4F�hone TYPE OF WELL/PUMP: NEW WELLF WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �_ SEWER LINES 72!�' DISPOSAL FLD.. __ PROP. LINE �0- FOUNDATION AGRICULTURE WELL OTHER WELL LLL -a PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fre* 4- W'E'E' P(A+„(O'qs� O Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'I Public 11 Other 11 Delta Depth of Grout Seal 3 �'S Type of Grout I I Irrigation _Approx. Depth1 1 Eastern Surface Seal Installed by atlAdl 194 . S ) Repair Work Done U �j�Type of Pump � H.P. State Workpone_ Well Destruction O Well Diameter ~ Sealing Material i Depth AU - 32 Q y S 7i9nfi S641 Depth S Filler Material i Depth SSS - 33' 'OGS �y TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is r 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 table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of tines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby certify that t 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: "1 certify that in the performance of the work for which this permit is issued, 1 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 7st call for all required inspections. Complete drawing on reverse side. / / Signed x �� /dz�w� Title: 4/Wi W�" C�,tedQ51� Date: G Z —� FOR DEPARTMENT USE ONLY -1 �-// Application Accepted by Date '� ` �P Area v O l Pit or Grout Inspection by U Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services + Rovironmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. . EN 7126 111EV.I/R Sr �� e,1 �- a- 6 (� j �� Page 13,bEH 742i