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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALT1q1#VI ENVIRONMENTAL HEALTH DIVISION --ffl: r.IVE 445 N SAN JQAQUIN, PHONE (293420 P O BOX 2009, STOCKTON , A# - A ^ 1�_ DEC 2 1 IN3 PERMIT E%PIRES 1 YEAR FROM An'17srMfNViRQNMENTAL HEAL, H VICES Application is hereby made to San Joaquin County for a permit to construct and/or 'natal'a workherein s 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. 2 4� 2 0 GRAA17 L //✓E R o19� %^ C `/ i ti e aa.o« Grp / Lot Size/Acreage �-r Complete in Triplic ItMV # _ FERM�T�SER 2 �� 719,S T fARM S -N C 7� /DS�E �D/9D `�OPhone ��J — �p� ( Owner's Name Address I CK Al CASH I,✓L /?3�v S• SARA%G�9 - S..c �✓,t�-cii�/E -P' S'T� � ��o�i �1 / Contractor 4D(// &L4 . PRIM,✓)' Address .P�1TG� Cog `I�7o License No Phone - 023 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ ? PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well Tv' Y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. /*A PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation �/ Dia. of Well Casing Z XDomestic/ Private K Gravel Pack Tracy Type of Casing_._�,j/t_ 114 Specifications S� �D Il Public � fl Other I -I Delta Depth of Grout Seal 41 i. ��1 ly Type of Grout /✓EAT CEiff.J I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by AD✓AAieZ PRJ111AJ4 CO SNL Repair Work Done ❑ Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 3 Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: /,///, available within 200 feet.) 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 ❑ No. & Length of lines Total length/size— FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ le 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 o4 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 inspections. Complete drawing on reverse side. ee g Signed X_ f / . Title: OAIMIR �S 46,1 Date: /2 — 3 — / 3 V,9AlcC So%/%CCN o �� 4IEX f} . le,455 1-1 FO DEPARTMENT USE ONLY Application Accepted by _ Data Area Pit or Grout Inspection by /' ' `_n.3 Dated _5j5 Final Inspection by v� ( Date T Additional Comments: /t Applicant - Return all copies to 00, • EH 13.24 (REV. iiH 5) EH 1 4.26 San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 9520 FEE INFO AMOUNT DUE AMOUNT REMITTED CK Al CASH RECEIVED BY DATE a�s5 ? � j6 3 HONK` �