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. Eli 13-24 IREV. I/ Si EH 14.2e FOR DEPARTMENT USE ONLY Application Accepted by ---- Date Area Pit or Grout Inspection by • - Date 0 fr Final Inspection by Date Additional Comments: 25 477%)_( ) 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 952 FEE INFO AMOUNT DUE AMOUNT REMITTED CK a CASH RECEIVED BY DATE PERMIT .NO . — --- ..--. 4<c) _S;60ibV 3ic7 ) ADPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL RRAT.TH 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. Job Address '-i2(-1 N. -1/6?() 16,0 ()AI j 14 f i (. cyc, ,:-,--er,1 r p....„(,.. t s G ( c.1_44C0--1,61, 1-, Owner's Name aasiL, (.kV (0(9-4_ 1 j ( )C Address 'Fl(PP 01 01-11\115fi.01.,01,1 / HOW -h c i A - a - v \/ 61( ' IL 'Pone 'St-pc-Li-On r c)67 — 54 74-- icZ l' _ ,_ Contractor iitc_A -R-Ax irv,-- Address (.9...(is 2,S c-- . i 'A.'" K-r7 ±7. License No I-) i,--12.3.C-D (6 Phoni 6.)-1) -16 S - 11-2-- TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT C.1 DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER CS Monitori Well•sitcN ''C-) IL--e,.() DISTANCE TO NEAREST: SEPTIC TANK /V A SEWER LINES >‘:•)-S / DISPOSAL FLD N A PROP LINE 2! FOUNDATION > ( (-.)° / AGRICULTURE WELL N A OTHER WELL 2 1 °O PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation I 2 " • Dia. of Well Casing 4 n Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing C- -`1--(-) 'P V (--- Specifications 1'1 Public 0 Other Fl Delta Depth of Grout Seal (..) - a c) Type of Grout N ,2-cut- I I 1 Irrigation *L:_.2Approx. Depth )(Eastern Surface Seel Installed by Repair Work Done 0 Typo of Pump H.P. State Work Done _.r it' Sealing Material & Depth Well Destruction 0 Well Diameter IVI C) i i 't c i i i( Depth riller Material I. Depth , ,:e.l, TYPE OF SEPTIC ORK: NEW INSTALLATION I 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application arid 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting sionature 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 requir "(es,cyhs. e drawing on reverse side. Signed X _ „„ Title: .kf 7 -7 CitySt2)C--0-3() Lot Size/Acreage Date.