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APPLICATION ° SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P 0 BOX 388,STOCKTON,CA-05201-0388 PERMIT KKPIRES 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 Development Title Section 9-1110.3 and Section 9-1I15.3 and the Rules and Regulations of San Joaquin County Public Health Services. i -P1 Job Address L 0 City Ira C Lot Size/Acreage nn 14475'0 c 1Pt,*l24&. 41M r t l ld r.L ti-, n7�t — .,� Owner's Non" _ Address ki f dt C • zPhone 0 Contractor frffz,041 Address Y ul'/GflRettse No._Y � _ phone i TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM AEP.,AIR D 'OTHER ❑ Monitoring Well ❑ M DISTANCE_TO NEAREST,SEPTIC TANK-_ o p SEWER.LINES_ DISPOSAL FLD. -- PROP. LINE FOUNDATION AGRICULTURE'WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIORIS 1 to ❑ Industrial ./ ❑ Open Bottom ❑ Manteca Dia. of Well Excavati pomestic/leaf/ * Dia. of Wall Casing y ravel Pack racy Type of Casing— Specifications I'1 Public f.l Other 1-1 Delia Depth of Grout Seal Type of Grout r ,�7� I I Irri0ation (v 5�Appror, Depth I I Eastern Surface Seal Installed by ! Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Wolf Diameter Sealing Material i Depth Depth_ Filler Material E Depth TYPE OF SEPTIC WORK: NEW INSTALLATION r 1 REPAIR/ADDITION I h DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.1 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _.� Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sirs Number e° SUMPS Ll- Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS ❑ 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 o) 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, 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 taws of California." f The sppiican call If ail r u ad inspections. Complete drawingon se side. Signed X. Title: — Y Data: � F f DEPARTMENT USE ONLY t V " , // Application Accepted by Date Area ]C� Pit or Grout inspection by Date Final Inspection by Date Additional Comments: [ Applicant - Return ell copies to: San Joaquin County Public Health Services E Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 a CK i INFO AMIOUNT DUE AMOUNT REMITTED H RECEIVED 8Y DATE PERMIT NO. • EN 17-24 Y . aI/p sr