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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE$; ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3�0 P O BOX 2009, STOCgTON, CA 95241 PERMIT EXPIRES 1 YEAR FROM DATE I SW 0 (Complete in Triplicate) INV # Application is hereby made to San Joaquin County for a permit to construct and/or instaU-'ttie'"Vtrk'1bTMin 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. Job Address :3t'// /j•I-Am/,J A,' ,r /_,e City 5 - CK:TrAJ Lot Size/Acreage 3yc"v S,T F%_ Owner's Name 5W9_Z'L- (�)/L- 6'114PAAJ"- Address /',0, &-; sl -1 '' `�Ll�t 7`/51xi Phone 6a, Contractor A!5e_0 �i�/I/ln?c'.th%irVfXNLAddress IVSD /s'lr�o!� lel /�a�rhSSZl7license No�S7-451/L» Phonti' 75L/ 7z _2� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK A)/1"' SEWER LINES -3FOUNDATION Ff AGRICULTURE WELL 4;/Zt OTHER WELL 6�)& PITS/SUMPS ti �1' INTENDED USE C7 Industrial Domestic/ Private 'I Public I I Irrigation Repair Work Done U Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Exca/v}a ion I Z i..J - Dia. of Well Casing 'V/nlLd Cl Gravel Pack ❑ Tracy Type of Casing_1'je.�_ Specifications Other I Delta Depth of Grout Seal / d r is Type of Grout SK-- 2� 'G-��ye G n c �,✓�r Approx. Depth I I Eastern Surface Seal Installed by �r Type of Pump H. P. M __ State Work Dobe Well Diameter Z f Sealing Material i Depth �,st)r1r'n Depth 411AOK,LS � Filler Material i Depth ODr_fLarup TYPE OF SEPTIC WORK: 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 CK RECEIVED BY DATE PERMIT' NO. INFO CASH Number of living units: _A6L1rq'_ Number of bedrooms,lam S1 F7 Character of soil to a depth of 3 feet: s,, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest. Well Foundation Property Line �AYME "010 LEACHING LINE Cl No. & Length of lines Total length/size RECEIVED/ r� FILTER BED ❑ Distance to nearest: Well Foundation Property Line 0 cE C 0 1 1993 SEEPAGE PITS I I Depth Size Number P� ire. it `'ILA)_TH SUMPS LI Distance to nearest: Well Foundation Property Line 1RrCd;tiiu�lL i'iEriLTH DIV 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 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 sublect 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 r uir d inspections. Complete drawing on reverse side. Signed X ^ Title: ��+`1cc.,r Date: fi 1 d7 ( 1 / FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by Additional Comments: Date /y ` 3 Area . Date Final Inspection by S� Date 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 5201 EH 17-24 IREV. I/ e 5. EH 11.20 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT' NO. INFO CASH S1 F7