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Signed X cL._ A 1 tL__ Date: 57-4 iqq Area 0 . Dated2f7 '- The applicant must call for all required inspections. Application Accepted by Pit or Grout Inspection by •JkA.t.,otti Additional Comments. ofsty,( Ler/ Complete drawing on reverse side. Title. GrAFF FOR DEPARTMENT USE ONLY Date Date 6f-LP Final Inspection by 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. lv Lot Size/Acreage 45-11.1 t bAj-z...e-1... It . Kitlf2A'rv% —,- i — Owner 4.'s Name CiAll..) a.,1 Address I t51 0 fakeir 11-AZEL17.‹.) Arria , -,--p.) Phone 2-04-1' i4c14. ' .As:r---lrileimr.: e 4... I/JfkebLIA/"." Contractor 11:-I-Cif--3 )..ff2... \*-Ii.. Address 2:f.-Z-5- ,--5% ..1-1.i.-7 ‘,17- • License No. (-75-7 4122-a Phone /.I.:1L i TYPE OF WELL/PUMP: NEW WELL 0 WELL REP-LACEMENT El DESTRUCTION Cl Out of Service Well 0 PUMP INSTALLATION C SYSTEM REPAIR CI OTHER 't. Monitoring Well c TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. Tnor. LINE 7--- 10L2-1 -5 DISTANCE FOUNDATION AGRICULTURE WELL OTHER WELL -f14464-6444424- I_U___' Z.L2,16-1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS P, Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation DieT-e4-1AielLCasing_ t•IC 64 C.1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing -619e.4413"ei r I'l Public Li Other 11 Delta Depth of Grout Seal Ty,fre_04_,c,""g i...,IL.A.— .c.pcif.-.... I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by ,,/,\,c.:,,Ard c..1D."4st.il-- _______ Repair Work Done Li Type of Pump H.P. &tate-Werk-Done f7‘.,.A:iitiLFL...N,:.) ('t4 Well Destruction CI Well Diameter Sealing Material Ii Depth /64-1,1 Tt C.4...3-e.. ,.---- Depth Filler Material & Depth ---&-.-1--"11.--- , TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No 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 Poopaw ne Peant eNr NI VEr, LEACHING LINE 0 No. & Length of lines Toll y017 FILTER BED El Distance to nearest: Well Foundation robe Le.p.k16" AN7.6 IY•Y4 Pti eLl AQ0 , SEEPAGE PITS I I Depth Sin t N V/ kA AL r Ai COOA, SUMPS LI Distance to nearest: Well Foundation T4, 74 i'l 1WirE s c DISPOSAL PONDS 0 DiViSMAi 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 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." Applicant - Return all copies to: Sa Joaquin County Public Health -rvices Nt00O3,21,3 Environmental Health Permit/Servi s ir 445 N San Joaquin, P 0 Box 2009, Stk ... 01 _ . EH 13-24 (REV. iiiisi EH 14.26 FEE INFO AMOUNT DUE AMOUNT REMITTED (*If CASH RECEIVED BY DATE PERMIT . NO. ri (4-''' P 42 163 4.-•.; frit-- ‘ 3 i lq Li 4').3).-30