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APPLICATION SAN JOAQU I N COUNTY PUBLIC HEALTH SERVICES 9s(c, 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 made to San Joaquin County for a permit to construct and/or install the work herein described. This applicaand is made in cceWllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules nd Regulations of San .Joaqu.tn County Public Health Services. n Job Add, ass 1�+ L -I�y� City Lot Slze/Acreage Owner's Name \ � C-50Q\C�S0" Address � � L �-�� 1—e �J 'V-'- - Phone 21''- o 4, Ll Contractor \ Address � � `�y��W t License No. 2c- `ii Phone 5 S* T'rPE OF WELL/PUMP: NEW WELL ;R; WELL REPLACEMENT F1 DESTRUCTION D Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 Industrial E) Open Bottom ❑ Manteca Dia. of Well Excavation V 2 Dia. of Well Casing -x Domestic/Private (A Gravel Pack f7 Tracy Type of Casing_. _-L►160 V*J C Specifications Pi hlic l-1 Other / I-1 Delta Depth of Grout Seal L Q Type of Grout gay%\ntm\-t \ 1 Ivittanon 4:9"pprox. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H P. State Work Done Weil Destruction ❑ Well Diameter �o • Sealing Itaterial i D pth (� . Depth Filler Material ; 116pth i V t rF't OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION II/D �TRUCTION I I (No septic sysum permitted it public rower is T available within 200 feet.) Installation will serve: Residence _ Commercial _ Olhar/' (� Number of living units: Number of bedrooms _. i 1\I Character of soil to a depth of 3 feet: Water table depth SFPTIC TANK ❑ Type/Mfg _ ape No. Compartments PKC TREATMENT PLT. ❑ Method of Disposal Distance to nearest: 1, Well Fou tion Property Line i L CACHING LINE 0 No. & Lengtnrest: f lines Total length/size FILTER BED CI Distance to Well Fou alio Property Line . SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundetion Property Line DISPOSAL PONDS ❑ I hafeby certify that I have prepared this application and that t work will be done in accordance with San Joaquin county ordinances, state laws, and ,,,les and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the foil o no. "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson in such manner as to become subject t6'workman's compensation laws of California." Contractor's hiring or sub-contracting signature comf es the following: "I certify that in the performance of the work for which this permit is issued, I shelf employ persons subject to workman's compensa- tors laws of California." The appllc n must can for all required infpeetions. Complete drawing on reverse side. f}nedno C,r- Title: 1Q' �t� Date: -Z�_C�3 FOR DEPARTMENT USE ONLY �t Application Accepted by _-—_ ____ _-- _--— Date Date r - 0?3 9�3 Area a 16 RAA Pit o<9Pnspection by^ Date Final Inspection by Date Additional Comments: Avolhant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE FO AMOUNT /DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. EH i3),r11Ev rr MSS EH 14 20U)A.)