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t I4, i� y APPLICATION' `W, ;. +S JOAQUIN COUNTY P ' F.. C HEALTH;"SERVI CES ENVIRONMENTAL HEALTH DIVISION -� 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, ' STOCBTON, CA 9520 PERMIT IR IRES 1 YEAR. FROM DATE ISSUID . , (Complete ln ''Triplicate) Appllcationiis°,hereby; tmde to San Joaquin County for a permit to 6onatruct and/or install. the work herein described. This application As invade in compliance with San Joaquin County Ordinance No. 549 and i862 and the Rules and Regulations of San Joaquin County'Public, Heaelth Services. ; Job Address D� F '--��I �Vf' _ __ T City L6 r Lot Size/Acre' e I�� C 'jJJIII Owner's Name: C��'- Address R• rz6b 6��t 6.WDQDb IL _ 1 Phorie` Z oq 54 -3 Contractor (7t 12t�Ri Sl�,�ea Address 7y/a0 fib WDO Nev ;s �[ icense No. Phone 520-'P2fr- 73 TYPE OF WELL/PUMP: NEW WELL - -% WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service well ❑ :-PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TOfNEAREST SEPTIC TANK SEWER LINES _ ..1(>G- DISPOSAL FLD. PROP: LINE abr" FOUNDATION AGRICULTURE WELL OTHER WELL X50 PITS/SUMPS. INTENDEDI'IUSE u TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � F) industrial 1 f i❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia of Wel! Casing f:3 Domestic/Private I❑'Gravel Pack, ❑ Tracy Type,of Casing_ (.QVC S r pecifii ations I'1 Public ;� .;4 Other Srt'Nb i l pelta Depth of Grout Seal �} Type of Grout Or t I I lrrigation j -OApprox. Depth fid'Eastern Surface Seal Installed by __F1 USA 4 roti W4 It G ov;e r^ T T, Repair Work Done U ;Type of Pump H.P. : State Work Done Well Destruction ? O Well Diameter �' r 9 Sealing Material A Depth } i 1 'Depth Filler Materitil &_Depth TYPE OF SEPT,IC:WORK: ' NEW INSTALLATION I I REPAIR/ADDITION 11' -DESTRUCTION I) iNo septic stem rmitted if p y pe public sewer is available within 200 feet.) ,I l Installation will serve: Residence Commercial Other lam! Number of fivinp units: ' Numb' r of bedrooms Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK'.! U Type/Mfg Capacity.. No. Compartments PKG. TREATMIENT PLT..0 Method of Disposal.- Distance to nearest: Well Foundation Property Line LEACHING LIN F m Cl No. & Length of litres Total length/size FILTER BED [_] Distance to nearest: Well Foundation Property Line SEEPAGE PITS " I 1 Depth Size Number SUMPS 4 Lt Distance to nearest: Well Foundation Property Line. DISPOSAL PONDS C7i I hereby certifyllGhat I have,iprepared this application and that the..woi'k will be done in accordance with San Joaquincounty ordinances, state laws, and rules and regulations of the San Joaquin County si Home owner orl)icensed all'ent'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 perion'in such mariner 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." r The applicant ripustcall for4ill required inspections. Complete drawing on reverse std Signed x- -- fJtt�i4s ��._..:..�._. Title: ro �.e�f 7`" Date:: Zg j3 FOR DEPARTMENT USE ONLY ` X16 Application Accepted by Data -Area U>c i Pit or Grout Insection by !i Date'` Final Inspection by i� qgAdditional Comments: Applicant �Returri all copies to; San Joaquin County Public Health Services w r:. Environmental Health"Permit/Services . ° 445 N San Joaquin, P O Box '2009, Stkn, CA 95201 FEE AMOUNT DIE AMOUNT REMtTTED Gk RECEIVED BY DATE ;PERMIT'N0. INFO, CASH .. 7�7+ £H 13•24 SREV,t i n 51 1 �l EH„-2e IF