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APPLICATION . S '�TOAQUIN COUNTY PUBLIC HEALTH"'SERVICES ENVIRONMENTAL HEALTH DIVISION 3 445 N SAN JOAQUIN, PHONE (209)468-3420 _ P O BOX .2009°," STOCKTON, CA 95201 " PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED ;:: , (Complete in;"Triplicate) i Applicatioa�is!hereby made to SanlJoaquin County fora permit to construct and/or install.the .work'herein described. This l applicationlis,made in compliance with San Joaquin'County Ordinance No. 51+9 and 1862 and the Rules rind Regulations "of.San Joaquin County'Public Health Services." Z Job Address D L �Vl: it City Lb A Lot Size/Acreage IDR I-L f SO E D 'd 06b Phone- Owner's hone-Owner's Name Address i. F] rJev icense No. �w I Phone 570 of 2y- 73 Contractor C-n9 4 S dfI?A Address 74b0 �� "wr�o TYPE OF WELL/PUMP: NEW WELL ..WELL REPLACEMENT CI : , '.DESTRUCTION ❑ Out of Service well ❑ Il PUMP INSTALLATION ❑ . SYSTEM REPAIR 0 OTHER ❑ , Monitoring.well DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES �a.."�" D1SP05AL FLD. PROP:'LINE .R FOUNDATION AGRICULTURE WELL OTHER WELL �✓�O PITS/SUMPS, i j: INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS" C} Industrial ❑ Open Bottom ❑ Manteca Oia. of Well Excavation Dia..of'Well"Casing C:] Domestic/Private ❑"Gravel Pack• 'J* C7 Tracy - Type of Casing_ QVC Specifications r I'I Publicp(I Other SQNb fl Delta Depth,of Grout Seal �' H�Si+ Type of Grout�po'� I I Iffigation "j1 -OApprox. Depth h(Eastern Surface Seal Installeli d by 1 u5 h r t LI C DOC it P1 Repair Work Done 0 Type of Pump H.P. State Work Done Sealing Material.& Depth Well Destruction, ❑ Well Diameter 'I 11' Depth Filler Mnterial:8' Depth 11 TYPE OF SEPTIC'WORK: NEW INSTALLATION I I REPAIR IADDITION 1?1 -DESTRUCTION l I (No septic system permitted if public sewer is available within 200 f6at.) Installation will serve: Residence_ Comrrierciel 'Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK "` "❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.ClMethod of Disposal. "t Distance to nearest:. Well Foundation Property Line LEACHING LINE': CI No. & Lengtti of lines Total length/size "! FILTER BED F ❑ Distance to nearest; Well Foundation" Property Line SEEPAGE PITS i I Depth .Size k Number SUMPS I ;f LI Distance`to nearest: Well " Foundation Property Line n DISPOSAL PONDS C7 k I hereby certify ttiat 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 cartifies the follo+niing: "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 sub-contracting signature cartifies 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'siqust all for all/required inspections. Complete drawing on reverse Signed X Y ipJeu�S � Title: ��`B?/37` - i pate:. Zg g3 I� 6 FOR DEPARTMENT USE ONLY Application Accepted by ' Date -7 Area U h 4' Pit or Grout Inspection by Date Final Inspection by Additional Comments; Q� Applicant :- Return all copies to: SanJoaquinCountyNiblic Health Services Environmental Health'Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201CK FEE i f INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT"NO. �y 1 jyft} '7� 3 . EH 13-24 IREV.I/"S) FY '' - VIJ lfll{. �� II q + fH 1e-2e