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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 in 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public` /Health Services. Job Address 6%Z5 S• e, J &�_ City4hde� Lot Size/Acreage /0 AC Owner's Name'�-E� 7ch/ Whh)/dd'r� ��, � Phone 7 Contractor Address m'"2-9 1 ?"ZO 1 .0L nL License No.� l S L Phone TYPE OF WELL/PUMP': NEW WELL ❑ WELL REPLACEMEN DESTRUCTIONFFW.Wt of Service well ❑ PUMP INSTALLATION 79. SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS %g ❑ Industrial n Bottom ❑ Manteca Dia. of Well Excavatio _ 11 — O pe ie_ Dia. 01 Well Casing /s 7<6omestic/Private Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public 1_.1 Other ,�yt�D� L1 Delta Depth of Grout Seal 6D Type of Grout I I Irrigation AppEbx. Depth I I Eastern Surface Seal Installed by 01 Repair Work Done L] Type of Pump H.P. State VVork Done ('e r _ Well Destruction f1 Sealing Material L Depth Well Diameter ` �+� t Depth (qnQ Filler Material i Depth �`' 1a ori '7O r C�irst TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESYRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of Irving units: _ Number of bedrooms Character of sod 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. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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 subcontracting 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 Cslifor 'rho applicantmu c ro ized in coons. C2e19J&Wdrawing on reverse aid Signed Title: _ Date: s•�' /7 L I Ia FOR DEPARTMENT USE ONLY Application Accepted by rA Date SIT Area _ Pit rou Inspection by Date-Z— Final Ins tion by Date G Additional Comments: • , Applicant - Return all copies to: San Joaquin County Public Healif Services �. Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 'FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. /I/�f i EN t3.]4IREV.1/x51 rl+t+�.— I�f ` —23 6 y EH t4-aE J 7-9tI wh is .O � 7 / I /