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' APPLICATION S 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 vork herein described. This application is made in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin CountyPublic Health Seervrices'. Job Address ksar City SLA& lot Size/Acreage ��• o Owner's NameL Address )6Zq �. 4 /R//Vii Phone( 6 - Contractor C,J/.4rk Address . D License No. Phone u9 Z' 76- TYPE OF WELL/PUMP: NEW WELL ❑ / WELL REPLACEMENT DESTRUCTION ❑ Out of Service--W-11 PUMP INSTALLATION)< Cn41Eu� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK S'04FPLINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL *PROBLEM AREA,ONSTRUCTION SPECIFICATIONS ❑ Industrial — ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t71 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l Public I:1 Other fl Delta Depth of Grout Seal Type of Grout N I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth Ir' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sawer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth l SEPTIC TANK ❑ Type/Mfg Capacity No. Compartment E PKG. TREATMENT PLT. ❑ Method of Disposal rn Distance to nearest: Well Foundation Property Line N LEACHING LINE ❑ No. i Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line V SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 subcontracting signature certifies the following: "I certilif 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 must call f wired i ci o late awing�Io//n rev rse side._ / Q"'� Signed Title:/1 Q7i.�-nom Date: I— 7 — 1 'r� FOR DEPARTMENT USE ONLY Application Accepted by __1__'�L`_id'' Date �'7i -/ Z. Area K �Ct✓.� Pit or Grout Inspection by Date Final Inspection by .ten-P-p Dete.y�`f �� ' Additional Comments: � Ifo— '1/ � ��• gq Applicant - Return all copies to. San Joaquin County Public lealth Services /Environmental ttces !n 445N SanJoaquin,P 0 Box 2009, Stkn, CA 95201 �� INfO AMOUNT DUE AMOUNT REMITTED )qC FEECK H RECEIVED BY / DATE PERMIT'NO. . EH 131-24 IREV.ri n ei O� ✓ �' t C(:^•7 IZ. EM 14]a