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�fyr`.t^`. �: _ �-ate•-.,..,,...ter-- f APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 f 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I Q3 I 17. t?DAd City JE_ i.0 La Lot Size/Acre e as __ .zo AIJ. Owner's Name 241L 51Z L(w►11.4_)I Address J42 �. ✓ted A�-c ±J�12 ) `5CAC.o� r Phone t A8"14 7 Contractor Address License No. Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION ❑ Out of Service Weil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER Q Monitoring Well 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 U industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ' Cl Domestic/Private 0 Gravel Pack . 0 Tracy Type of Casing- Specifications Il Public 1-1 Other Cl_Delta- Depth of Grout Seal Type of Grout I Irrigation —,Approx. Depth -I l Eastern Surface Seal Installed by 'Repair-Work Done- U Type of Pump H.P. —"State-Work Done�- Well Destruction ❑ WeII Diameter Sealing Material 6 Depth j Depth Filler Material i Depth �lJ" TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRJADDITION I,} DESTRUCTION I I (No septic system permitted it public sewer is 4 available within 200 feet.i Installation will serve: Residence Z Commercial_ Other ,S= �`- Number of living units: ._L .Number of bedrooms Character of soil to a depth of 3 feet: I4 L-64r^ `' "`' Water sable depih S-` i SEPTIC TANK. iEr Type/Mfg _ T �Ut.,rlkEdl r Capacity �!No..Compartments 2- PKG. TREATMENT PLT. ❑ l Method of Disposal �� ' Distance to nearest: Well l2.0 Foundation 1 f, s„ f� Property Line __ 7 [/ y� d LEACHING LINE LY No. & Length of lines 0 Tota! length/site .x a FILTER BED1 C.1 Distance to nearest: Welt LO Foundation I`'7 Property Line AWK _ m - - - V) SEEPAGE PITS It Depth I �,,,•,_—Size A75 Number Number SUMPS Distance to nearest: Well Foundation QProperty Line ` `t DISPOSAL PONDS ❑ I hereby cenify 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." i The applicant mug.calljor all required-inspections..Complete drawing on reverse side.-- - -- !i Signed Title: vJ-4i •" ` ` Date: 3 2 3 r FOR DEPARTMENT USE ONLYLZN �1 q 4 Application Accepted by Date 3"a 1 3 Area 02 1 Pit or Grout Inspection by DateFinal Inspection by Date Y Additional Comments: U�"a - w K• f 15 Applicant - Return all copies to: San Joaquin County Public Health Services USG Alt b1l,/'t- Y�� " i Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 i ` FEE AMOUNT DUE FAMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH ff"r;i: InEv,ri�ar SN coo r0-0 3830 3^D3 �[3 93