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APPLICATION r^ I A N COUNTY PUBLIC HEALTH SERVICES { SR RONMENTAL HEALTH DIVISION - it 445 N S JOAQUIN, PHONE (209)468-342(} . ISTD .rapt gar n B % 2009, STOCKTON, CA 95201 FAC# PERMLT E�IRES 1 YEAR FROM DATE ISSU ` z'r �1�( �} (Complete in Triplicate) �5 A ANV.# oe ula County for a permit to construct and/or install the vork herein described. This • ts, aace vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Service/s. //.. Job Address 651 �• A1.-�Or'C Jt./ City 55041. QA Lot Size/Acreage t L gt� CO Address 3?_n 9— A SIcr4W.aw,{[J 9s$/7Phone �G —3 Owner's Name GIti O rti< ✓� f p �Qtyrirry Contractor n5� `� 4ssOezc,fe.s Address A�/�alczi!}Ti✓J� Lf{• �i456 License NoC��- %/0"1441one67i0)tM2.-/app TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well h✓ DISTANCE TO NEAREST: SEPTIC TANK �_-- - SEWER LINES ± 2- r DISPOSAL FLO. N14 PROP. LINE --F 30� AIA- FOUNDATION �Q_ AGRICULTURE WELL �_ OTHER WELL iy1L PITS/SUMPS NA' i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it ❑ Industrial 15_0p;_- BOttom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-S" 4-.0 P✓ Specifications I'1 Public ❑ Other Fl Delta Depth of Grout Seal LO Type of Grout t• G.a»f I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter - Sealing Material i Depth I Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. i Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number j SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 persona subject to workman's comPenss- tion laws of California." The applicant. ust call for a1 re it inspgctions. Complete drawing onreverseside. / /� sig Title:/� fob W;'W -lP/'�itbate: -2,43174- FOR 3 y¢FOR DEPARTMENT USE ONLY p , Application Accepted by Date c2 �— / � Area Pit or Grout Inspection by , '` v ""�T�`�'t-�_ Data //� Final In•paction by ? ct- ` Date Additional Comments: ✓ / Applicant - Return all copies to: San Joaquin County Public Health Services 3s j Environmental Health Permit/Services 445 N San Joaquin, ,P O Box 2009, Stkn, CA 95201 FEE I INFO AMOUNT DUEffM MITTED CASH RECEIVED BY DATE PERMIT NO. . EM I]-N(A EV.tin Sl E1424