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I` APPLICATION l 6`614 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 7 �' _ ENVIRONMENTAL HEALTH DIVISION I �� 445 N SAN JOAQUIN, PHONE (209)468-3420 1} P O BOR 2009, STOCKTON, CA 95201 J � 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 to made in cowliance with San Joaquin County Ordinance No. 5149 and 1862 and the Rules and Regulations of San JcAquin County Public Health Service/s... )nb Address _ !�C �JZ_�w /' �TL�_ City � �Lot Size/Acreage I JAW, Owner's Name r/✓ �ddross C �/�1 ' ' Phone �f l �J l(J Contractor /�'�Q1'C � s J� i(ddress License No. %X Phone rl�l �r TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT (-1 DESTRUCTION- t of Service Well O PUMP INSTALLATION O SYSTEM REPAIR [_1 OTHER O Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. or� _ - PROP LINE _7 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I } Industrial O Open Bottom L-I Manteca Dia. of Well Excavation Dia of Well Casing I ' Domestic/Private Cl Gravel Pack O Tracy Type of Casing Specifications 11 Public f l Other I 1 Delta Depth of Grout Seal Type of Grout i i Ifr,llation Approx. Depth I 1 Eastern Surface Seal Installed by _" - Ix/< Re air Work Done O T p ---_-- -- -- __-- —� — p �,,. Type of Pum N.P. _ State Work Done �f � � � � y•�� Well Destruction }�,� Well Diameter Sealing Material L Depth ! J Al. / ' Depth —_13 Z Filler Material i Depth tt1•F (1F SEPTIC WORK. NEW INSTALLATION I REPAIR!ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _. Commercial _ Other Number of living units: ___ Number of bedrooms Character of soil to a depth of 3 feat: ___ _._ _ ._ _ —Water table depth r SEPTIC TANK O Type/Mfg _ Capacity No. Compartments PKG TREATMENT PLT. L.l Method of Disposal Distance to nearest: Well _— Foundation Property Line LEACHING LINE LI No. fir Length of lines _ -__ Total length/size F11.TER BED CI Distance to nearest: Well _- Foundation Property Line _. SEEPAGE PITS 11 Depth __ SireNumber CIIMPS. LI Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS U I hereby cenify that I have prepared this application and that the work will he (tone in accordance with San .Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County A Nome owner or licensed agent's signature certifies the following: ''I certify that in the performance of the work for which this permit is issued, 1 shall not w 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 CslifofFile." F + The sppficsr)t mat It0.1q.i,.d insr^,FE .complete drawing on revs side. Signed X__ Title: ~ Date: FOR DEPARTMENT USE ONiV Application Accepted by _ _ Date Area _. 11 2 � Pit or Grout Inspection by - ate Final Inspection b. Data ow? Adrt�tinnd Comment: Zf srlII, nnt - Return all copios to: San Joaquin County public Health Services Environmental Health Permit/Services l 6 445 N Sen Joagnln, P O Pox 2009, Stkn, CA 95201 INFOFEE AMOVNT DUE AMOUNT REMITTED CK ECEIVED By DATE PERMIT NO . _ f. 11 14 fory 9