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APPLICATION 1"/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby sauce to Sad Joaquin County for a permit to construct and/or install the vork 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 ✓ ng AJ- .n ��1l� 9�/�/� J City Lot Site/Acreage 11 Owner's Nama�r'� � ITJs-Irz S /Y LWdLvJ[ Phone Contracts' ddress 356 icense No.� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ` PUMP INSTALLATION ❑ 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 Cl Industrial CFO n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing • Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \y I"I Public I R Other fl Delta Depth of Grout Seal Type of Grout — I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Tope of Pump M.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Piller Material A Depth TYPE OF,SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION STRUCTION I I INp septic system permitted if public sewer is available within 200 feet.) ` Installation will serve: R�eeaxidmkmca Commercial O Number of Irving units: �C N�of badr a, Characier of will 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 L 8 Length of time To�al length/site FILTER BED ❑ Distance to nearest: .Wall.4=�7 Foundation Property Lim SEEPAGE PITS IijiSepth. r+` sire_ iI Number SUMPS -LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby unify that I'have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and .. rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that intheperformance of the work_foc.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 unity that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compenW. r ti�Tlaas California." _ The applican all 1 NI req, it in w c plate rowing reverse i a. _ Date: FOR�� TM ENT USE ONLY Application Acceptor OY v"��w Ate ! ��Oa ar+n. Date, /�Area k./2— Pit or Grout inspection by/r�I_ / Date Final Inspection by Date a.. Additional Comments: l r' ^ _4ra// �h eW,34;-c _5V�-,fit+.. W/ 0-13dX_ PLATE Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services r 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 CI FEE AMOUNT DUE AMOUNT REMITTED CASH ECEIVED BY D If /TE PERMIT'NO. ti EN IREV.ir.si SiL ' / a 3� 14-N I EN It-3e C O