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APPLICATION SAN 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 l YEAR FROM DATE ISSUED (Complete In Triplicate) licatioa 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 vith San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. tp 1 ! ¢ 1 Job Address �Us� !�►__. ,Lral) 5'ttet! City �tQ CAt6 Lot Size/Acreage Ry,�u-MURP v sup 3l� Owner's Name fid O Address 7 � M+` �O Phone 7` Contratta 2G m/"M Addresses S�tCtOl1 License Ndl.?A?l'g Phone TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 /1114 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST SEPTIC TANK SEWER LINES &0—" DISPOSAL FLD PROP LINE FOUNDATION �D' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �f ❑ industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation !r Drs of Well Casing rl Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing___ ____ liifl- 5pecdicatwns — o f 1 Public I-1 Other 11 Delta Depth of Grout Seal -/� _ Type of I I Irrigation 2-LApprox Depth I I Eastern Surface Seal Installed by E�i'Ur►+ r ' ` Repair Work Done L] Type of Pump H P Stat Word Done ' Wall D�s`truction ❑ Well Diameter ��_ Sealing Material i Depth c• £ ' - ��nier�ia�;pati Depth _--?e" Filler Material i Depth GnZLP0 S;!,« _�yi . rn YP F SEPTIC WORK NEW INSTALLATION 1 REPAIR/ADDITION i I DESTRUCTION I o sa tic s stem p y permitted d public sewer a .� av able within 200 loot I ib Installeti will serve Residence C mercial Other Number of ng units Numbe of bedrooms a Character of to a depth of 3 fee Water ble depth I h� SEPTIC TAMC ❑ Type fg Ca city No Com manta PKG TREATMENT PL ❑ Mothod of D sal mtance to nearest Wel! ndairon Property Lino ' LEACHING LINE Cl of lines Total length/sae FILTER BED ❑ Dis\6Length to nearest Well Foundatxa Property Line SEEPAGE I/AG I I Depth Si: Number r SUMPS LI Distance to n at ell Foundation Pro Line DISP AL PONDS ❑ I 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 taws of California Contractor's hiring or subcontracting signature caniftes 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 ail r i ed inspections Complete drawingreverse side Signed Title `S Date IZ2/�Xlf FOR DEPARTMENT USE ONLY Application Accepted by �-E - , , .. Dare Area.Z 99 i I> Ph or Grout Inspection by Date Final 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 95201FEE Ka 35,01 INFO AMOUNT DUE AMOUNT REAAITTED `CASSHt RECEIVED BY DATE PERMIT No 13-24(REV iiA$a j iQ5 �� I �l�y �L ��//Il�s 3-Gvlf H 14-M r�