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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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. 4 R 7 Ce -,f171.1 r / MJDA I ^ CTiIQF,CT r;,,, CTbckThA/ Lot Size/Acreaee Name TalCX76-1) PLAT[,) t; Address G 3 2 SCXJTN EL rDaft A 0 ST Phone -209Q98 ' 110 � Owner's AMOUNT REMITTED Contractor F A)71V 1 3U1,AS _ Address P-6- 6<1131 MODEST41 License No. �e8�Q79 Phone f•S� �af��2! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION L-) Out of Service Well ❑ PERMIT NO. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ;06t" SEWER LINES 100+ DISPOSAL FLD. PROP. LINE FOUNDATION 3O FT AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 6 I icl Dia. of Well Casing12 lojc,� N Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing_._p.ke C Specifications $C � 40 I'1 Public Ftt Other 171 Delta Depth of Grout Seal 3h%d FT Type of Grout CEM&AX SLbP-Y 11 Irrigation _-_ Approx. Depth I I Eastern Surface Sedl Installed by COAJTRAC,_btt Repair Work Done U Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter .2 1 INS -11A Sealing Material & Depth &LcJU mac 3-9-.3c fr Depth 66 FT. Filler Material d Depth 03 M,A.1n 60-38 gr. TYPE OF SEPTIC WORK. NEW INSTALLATION ' I REPAIR/ADDITION i I DESTRUCTION I I INo 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 L� No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Founoation Property Line SEEPAGE PITS 11 Depth _ Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title: 6EO(A6t57'/A6E.A/T T6F GWItK Date: I1I gTg� FOR DEPARTMENT USE ONLY ° Application Accepted by ><';� _ Date �L Area Pit or Grout Inspection byT Date Final Inspection by ! - /1�F Date /�' Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Servies yV� Environmental Health Permit/Services �� 3� r 445 N San Joaquin, P O Box 2009, Stkn, C • EH 1324 (REV. +i n s. EH 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. nl) U11 R� r1