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s, . 1, APPLICATION �u 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}p m¢dez lisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Co c th Services. AC Job Address MW E 4""'"` %r - City"��/ Lot Size/Acreage ✓d� /" Address L� � Phon._ � Owner's Name Contractor mss+ • •�� Address �" r License NoPhone ��T r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK l Do SEWER LINES DISPOSAL FLD. ISO PROP. LINE LO FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,6 Ci Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing'Y -4ieOomestic/Privateik Gravel Pack O Tracy Type of Casing___ ef4Specifications I'I Public / Other Fl Delta Depth of Grout Seal 1—�/ )`U f Type of Grout C—C-^ � I Irrigation ;1030'9 Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump .S(ld H.P. 3 —_ State Work Done iCOt'� Well Destruction O Well Diameter Sealing Material i Depth 1-3 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 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 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 Cl No. b Length of lines Total length/,size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number i SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 pefformance 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 perrrtit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call all r ued inspections. Complete drawing on reverse side. Signed X Title: OG✓�'-�� Date: ` ?r A DEPARTMENT USE ONLY Application Accepted by C^A1_1 "_` ' Data Area "' Pit o u spection by Date �T Final Inspection by Det S /2 �3 Gro Additional Comments: hib / Applicant - Return all copies town o q in County Public Health Services / '?3 etK seaftri �Jl+ � '�"►�� 445Environmental PermiJoaquin, P 0 Boxt2009,r1Stkn, CA 95201 ces ��KG /tel 1 �� ISI w4e FEE AMOUNT DUE AMOUNT REMITTED CKill RECEIVED BY DATE PERMIT'N0. CAJ45:' o 01 F CASH G� . EH 13119 21111EV.1/015) j �3 `3 EH 14 J 28 \ t ��