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7,17 r 6t ved APPLICATION SAN JOAQUIN COUNTY PUBLIC WEALTH 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 Joaquim Czunty for a permit to construct and/or install the work herein described. This application is made in compliance with Sam Zcaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 0 dAlloAl 57/2.e• t SCOCgThd Lot Size/Acreage 0.5 -AcIP--E- ..OlOW r.-...m...v.p. diti W A/ .1"6 CCId°1CY Address g /0° SIE/4,4-6i 1.0,4",6-ce5,64- ?PO Owner's Name ..1 Phone OX3)723-46&8 ;233 Fi-r7.4ozAu, ST. Contractor Wr--sc OAZMAT Acz.,ns Fves&C-14C CCP-Dc1,44-iCA- %'/License No. 55ifi79 !C57 Phon0/6)63E-1276 TYPE OF WELL/PUMP: NEW WELL'S. WELL REPLACEMENT El DESTRUCTION Cl Out of Service Well 0 PUMP INSTALLATION .7_.- SYSTEM REPAIR 0 OTHER 0 Monitoring Well A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE YO. i FOUNDATION ci AGRICULTURE WELL OTHER WELL Lo/ PITS/SUMPS INTENDED USE TYPE OF WELL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial 0 Open Bottom -.C. Manteca Die, of Well Excavation '8- //4)C4' Dia. of Well Casing Z -11444. Domestic/ 4E7 0 Gravel Pack 1- Tracy Type of CasingTVC.- '6Ci4. 40 Specifications 471---54-Zr ---4•1331/4/ Xi 1'1 Public *1 Other 5 44:40 PACe- X Deit6Tblip,U Depth of Grout Seal 5.8 ''''F-1. Type of Grout derr Ceine2,I1 1 i irrigation Approx. Depth Eastern Surface Seal Installed by CC1A;Tra41IT1L. (Ltil. 44-AtAA.k1' ) ____ Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK NEW INSTALLATION _ REPAIR/ADDITION I I DESTRUCTION I I No septic system permitted il public sewer is available within 200 feet.) ... Installation will serve: Residence Cormier-O.-al Other Number of living units- Number of becz-xims ___ 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 neartm: Well Foundation Property Line LEACHING LINE 0 No. & Length of Ie-.es Total length/size FILTER BED 0 Distance to nearesz Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearer= Well Foundation Property Line DISPOSAL PONDS n I hereby certify that I have prepared this applicaoon 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 pet 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 suc:ect 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 call for all required inspections_ Complete drawing on reverse side 5C-E ACZAC44-el>) Signed Tide: 6/4 DEPARTMENT USE ONLY 47L 3 •Di Date Area \.) Pit or Grout Inspection by Data Final Inspection by Date Additional Comments- V- So ,1 brj kW Applicant - Return all copies to: tan Joaquin County Public Health Services E:vironmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 pate 4,//0/7i-f Applicat ccepted by Eri 13-24 IREV. 1/ ,4 5) EH 14.25 FEE I INFO AMOUNT DUE AMCI-NT REMITTED CK 4 CASH RECEIVED BY DATE J6i $ 'Sf II 1710. 1,2.”:1-1 OD3r-