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APPLICATION SAiv -.JAQUIN COUNTY PUBLIC HEALTH ,ERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 Job Address ' Lr �ti�s� '/" "� City `CA.0 Lot Size/Acreage �' 3-�6, C, exe, 16 )Owner's Name OW eC t 12-012-041a ' Ck IWyS aril:Address 4GO� OAT t 4 11V\ �r A T lcyo( PhonA. I �4 1 411 co Contractor S VTa-�X EXLIOAddress 1 ' C^ EO U7� 1 <<;C( t��t t11TLC.- 5-1 373-`M, icense No. Phonof G� TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT C1 DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well CW 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 Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 n O Cl Domestic/Private ❑ Gravel Pack R Tracy Type of Casing_ N1a Specifications I'1 Public )q Other bcfe_V,4,1tS F1 Delta Depth of Grout Seal \D Type of Grout 10�?i1�n�{e, Approx . Depth I I Eastern Surface Seal Installed by ��S r?f 5K�''�c' EXt�10C�} I I Irnpauon lC ►Lr Repair Work Done Ll Type of Pumph. H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence_ Commercial_ Diller It Number of living units: Number of bedrooms .-, Charact Water table depth SEPTIC T POSt-It Fax Note 7671 Date 5-5'Ot5 Pages 110. No. Compartments PKG. TRETo From Method of Disposal n ?-OtJ �u Property Line S Co./Dept. Co. SSL \ LEACHINI Phone# Phone Zoe•#Ll Let. _ Total length/size a3�1i FILTER BI Fax# Fax# Property Line -ll - l(o' SEEPAGE _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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: "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 must call for all required impactions. Complete drawing on reverse side. Signed X �(�N� \% �l.1 lG�:� / �LVV--✓vy`�itle: h -, C I Z,&)),\ Date: � �1 FOR DEPARTMENT USE ONLY 11 „ Application Accepted by \ Date T l�~ Area Pit or Grout Inspection by Dat=� 7� Final Inspection by Date t 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 IJP^ EEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED By DATE PERMIT NO. Inage I3A EN 13-21(NEv.I/As) L EH 11.2a Vv U \