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Signed X ,( Date Area Title: 4/2 P Date: //) 3 ( c;4•9., Data ///1/if-- FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by Date Final Inspection by Additional Comments• Applicant - Return all copies to: San Joaquin County Public Health S ices Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 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. Address City/--e....4ty-O Lot Size/Acreage , V .,--, Abiesdr- CA- Owner's Name ri s'a-%0‘. L g. Address F 6?67 5 Pc. , -zei Phone (:Air) C-pq-Cri 5 r. _A..._v,_ i i Contractoreet4C-140 e...,5 .-1-- Address R., 7Y / .fitel ie-i ieif.‘kiLicense No. vy4;4. 24) Phont62e7)517-5.;74 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ii DESTRUCTION 0 Out of Service Well Cl PUMP INSTALLATION Cl SYSTEM REPAIR El OTHER Cl Monitoring Well g DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial 0 Open Bottom CI Manteca Dia. of Well Excavation (3- ,...,:_ts. Dia. of Well Casing 2 ,,--e-4- . 1-.1 Domestic/ Private CI Gravel Pack 0 Tracy Type of Casing ili— Specifications 7C4el Cie) 1'1 Public r.1 Other 17 Delta Depth of Grout Seal S---q ' Type of Grout (e- ........--, .)-- 1 I Irrigation Approx. Depth I I Eastern Surface Seal Installed by C3 1---5 __ Repair Work Done LI Type of Pump H.P. State Work Done Well Destruction Cl Well Diameter Sealing Material & Depth e.d io r-k- riZ Depth Filler Material & Depth ,4 , cite/Li. 16 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REF'AIR / ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is i.,4, 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 PIT. Cl Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED D 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 Cl 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." The applicant rst c ire inspcti9crs.,CompIete drawing on reverse side. c); . EH 13-24 IREV. i/m5) EH 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PERMIT NO. /41-1 43`6,