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Application Accepted by Pit or Grout Inspection by Date Additional Comments: 45 6,-k,44. FOR DEPARTMENT USE ONLY Date 5 A rea Date Applicant - Return all copies to: San Joaquin County Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 APPLICATION SAN ,k/AQUIN COUNTY PUBLIC HEALTH SzatVICE4,4., r ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN , PHONE (209)468-3420 t P 0 BOX 2009, STOCKTON , CA 95201 Application is application is Joaquin County SEP 2 6 19F''' PERMIT EXPIRES 1 YEAR FROM DATE ISSUBENViRONMENTALF -0 (Complete in Triplicate) PERMIT/SERVIC hereby made .t-o Sam Joaquin County for a permit to construct and/or install the vork herein described. This made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Public Health Services. Lot Size/Acreage Job Address -7 8\ S A- -I City 5T-tC4C15 d-sj Contractor L3S51-"C-X Address TYPE OF WELL/PUMP' NEW WELL V PUMP INSTALLATION LT, DISTANCE TO NEAREST: SEPTIC TANK >100 FOUNDATION I I.C) 1 SI 57 1 (A1 e). StDx 14,6%4 L....1.5p-c.License No. S.'S 219 g Phone 772,--J1(? WELL REPLACEMENT n DESTRUCTION :.:1 Out of Service wei 1 C) SYSTEM REPAIR LT, OTHER 0 Monitoring Well )0t1 SEWER LINES )1 OC DISPOSAL FLD '21 ZK,) PROP. LINE >••ez, AGRICULTURE WELL >' (-9 OTHER WELL '`,.1"' PITS/SUMPS 1.1PLL0,p Owner's Name t )24 Address 110(1 1:>14 AVE / Al% es Phone INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C") Industrial 0 Open Bottom 0 Manteca (71 Domestic/Private Zt,Gravel Pack 10 Tracy I'l Public (Ti Other n Delta I I Irrigiiilion 5S- Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump Well Destruction 0 Well Diameter ro" Depth 55' TYPE OF SEPTIC WORK: NEW INSTALLATION ' I REPAIR/ADDITION 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. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl 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 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 snail not employ any person in such manner as to become subiect to vvorkman'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 whicn this permit Is issued, I shall employ persons sublect to workman's compensa- tion laws of California." The applicant mus all for all required inspections. Complete drawing on reverse side. Title: rA Date: Dia. of Well Casing Specifications Type of Grout CerherrifSehrteAsi M.P. State Work Done Sealing Material & Depth 3o'- (:)' Filler Material & Depth :f 5-5 — ' Signed X (712-719q 4,1 (=t) Dia. of Well Excavation I° Type of Cas.ng$04.. go ev c_ Depth of Grout Seal 30 13-24 IREV 1,15) Eli 14-26 FEE iNFO AMOUNT DUE AMOUNT REMITTED Cx s I RECEIVED BY CASH I 1 DATE PERMIT NO. 94/Se40.5/F5 Mild Sy./ 0.? /549?Y /64: 9'