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APPLICATION SAN 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 (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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1100 S ■�/� ' e Q Job Address ""a � 1 City_I�"� — Lot Size/Acreage Z97)( 1 U Owner's Name R,_%Qebl Q d+1 Address 10415 vsH Phone �- y© �;re-cam St3G _� Bvsr,1� S � +-Lt � t�;•i 9`scx a� l>` "A tlzi7�J q0q-33x✓-ef�otp ContractorMi�AA-t- D1�r Address Z3T _ License No. Phan Z-7.i TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3 Monitoring Kelm � LV46. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IZo tri DISPOSAL FLO. PROP. LINE dr FOUNDATION s lL - AGRICULTURE WELL _.J&_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial r4* ❑ Open Bottom 41A ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [7 Domestic/Private 411.v ❑ Gravel Pack r4A C7 Tracy Type of Casing_ :V✓g- Specifications I'] Public AM XOthef h4h41101jA+oil Delta Depth of Grout Seal 16- &m �-- Type of Grout�l3?�� f I Irrigation pJA 740-Approx, Depth t I Eastern Surface Seal Installed by 152 Repair Work Done fC Type of Pump ki1A H.P. 14 I _....._.-_____ Stats Work Done_ Well Destruction 40 Well Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE OF S T WORK: NEW INSTALLATION I I REPAIR/ADDITION I } DESTRUCTION i I lNo septic system permitted if public sewer is available within 201 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. & Length of lines Total length/size FILTER BED N /A n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 41A L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 cenifies the following: "I certify that in the peiformance 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." The applicant must call for q11 required.inam. ion owe drawing on reverse s+d #L Q r Signed X Title: T/ -S r W� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area `v Pit or Grout Inspection by Date /7Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE CK INFO AMOUNT Dt1E AMOUNT REMITTED CASH RECEIVED BY DATEr/J�` PERMIT'N0. 30t 1.3A . EM IHEV.„n5+ 14-M l4L • 'ry!L /f f !{J o V 3 EM ti��E