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i APPLICATION. SAN JOAQUIN 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 made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in cotapliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. ��•� APN 0-76- 330-L7 Job Address '?I P�D• City Lot Size/Acreage l CL '54 g - M Owner's Name 4 Address `� ,! �. Phone Contractor t'n Address C < • �7 g=MLicense No Phone ;�' TYPE Of WELL/PUMP: NEW WELL 0 + WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER>K �d i�ng well C] DISTANCE TO NEAREST: SEPTIC TANK hi SEWER LINES 2:2] DISPOSAL FLD. &18 _ PROP. LINE Zf_ FOUNDATION T AGRICULTURE WELL L! OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Weil Casing A F1 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing �� Specifications �� - — I.1 Public Other �P-4b[an Delta K Depth of Grout Seal -A _ Type of Grout E� I I Irrigation —Approx. Depth Eastern Surface Seal Installed by 5agc ' eA.I Repair Work Done 0 Type of Pump H.P. State Work Done IF Well Destruction 0 Well Diameter Sealing Material & Depth 72 meq_• &12jQ et NJa Depth / Filler Material & Depth TYPE OF 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.) Installation will serve: Residence_ Commercial _ !'Other Number of living units: Number of bedrooms Character of loll to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS Cl 1 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 m call for all required in coon on reverse side. Signed ` Title: _C� Z� J; -3-- -- Date: / ! FOR DEPARTMENT USE ONLY r (� Application Accepted by 9 Date Area 7 Ph or Grout Inspection byIftate 7 i 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 O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEO CKRECEIVED 9Y DATE PERMIT NO. INFO `y�Q% CASH . EH 13.241REV.IIns 1 � -M aO - L.� l ^ 0 i(/p/,30 —777cA EH 74.28