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APPLICATION . S JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009 , STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L JJw_ ; (Complete in Triplicate) Application is hereby made to Sm Joaquin County for a permit to construct and/or install the work herein described This application Is made in complimce with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services Job Address -�a��`-- �1-1�1/i�11//0/ i `7 �' �� - City ilk Lot Size/Acreage t' CL 5 4s&x,1-+10-- Owners Name Y sE t it �`•_��_1�?✓�'�'1Address � -7-N _k��'rSL,I +ti S-i. Sint W_t-a1-. ,L[ TS ZL Contractor ,7Z�' �X/��C,,eddress elll / License No(ce�, Phone Ste- -rrS�i TYPE OF WELL/PUMP NEW WELL' WELL REPLACEMENT 5 DESTRUCTION ❑ Out of Service well [! PUMP INSTALLATION ❑ SYSTEM REPAIR []��+�o .,ew_-FTHER ❑ Monitoring Well � DISTANCE TO NEAREST SEPTIC TANK SEWER LINES<SorAfbJ' DISPOSAL FLD PROP UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ndaaMrsl fyGiv,TC� ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing _ [I Domesticl Private C-Gravel Pack L7 Tr y Type of Casing_ If h DC7 Specifications I I Public 11 Other etta Depth of Grout Seal � � r Type of Grout1�1c�4� I <«' rtr., I Irno.ltlon _i Approx Depth I I Eastern Surface Saul Instailad by PYX p��vJGy�//(Y r c/y ii Repair Work Done U Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material i Depth TYPE OF SEP WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system perynl(led,t public sewer is available within eat I Installation wdi sary Residence — Commercial ___,__, other Number of living units Number of bedrooms Character of sod to a depth o eat Water table depth SEPTIC TANK ❑ Type/ Capacity No Compartments PKG TREATMENT PLT ❑ Method of_Disgosal_ Dtstance to nearest Well F aeon Property Line LEACHING LINE 0 No 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest all dation Property Lina -- - SEEPAGE PITS I I Depth Size mbar SUMPS LI once to nearest Well Foundation rty Line DfSPOSAL PONDS I 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 perrrwt is issued I shall not employ any person in such manner as to become subject to workmen s compensation Laws of California Contractor s hiring or sub-contracting signature certifies the following I cernfy that in the performance of the work for which this permit is issued 1 shall employ persons subject to workman s compensa tion laws of California " The applicant must call for all required inspections Complete drawling Dn rave side I Signed X_ y �•-� y ,t'cs`� -�- tr ?Vrr c_c-r Date FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Onto Additional Comments Applicant - Return all copies to San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2008, Stkn, CA 95201 CK If INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO IN 13 I41AIry 1/151 IN 1 ♦2111