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• APPLICATION SAN ..OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 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. C z Job Address / ' ��^'�/�/ L AVG City 57L0 ' - Lot Size/Acreage 31 Owner's Name 5G� i 6 1 I A-dares V c 6� z 3 f��l 6/211'/ Phon (SLe 6 75-41(, r-6-5 41l44 0 r¢ 7� CC!!yy'' Contractor ,!�rn �h Address ��5 4 GI1C_ S5 I/r, UP LAen e'No. 705a? PRbse �Z86-1o66 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION�❑� SYSTEM REPAIR ❑ POC,el, OTHER, Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ;> 11" z= SEWER LINES >11; C' DISPOSAL FLD. 0,1' PROP, LINE ice, r FOUNDATION L�( AGRICULTURE WELL / G'(' OTHER WELL� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,PICDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public n 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 Type of Pump I11H.P. StaWork Dona/4,/!e _ L Well Destruction ❑ Well Diameter Sealing Material i Depth c-. C -v . .� >Z• ?GI?-c. �2'/�/�� !7 /V C— K Depth "��5 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION 1 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 sod to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg, CapacityNo. Compartments PKG. TREATMENT PLT. 0 __—� Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to ell Foundation Property Line SEEPAGE PITS 11 Depth Number SUMPS LI Distance to nearest: Well Foundabo 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 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." The appil must ca for all required inspections^Complete drawing on reverse side. % Signer/X d. �i't ��'--��ftIs: AnR04.✓ Date: /7n� FOR DEPARTMENT USE ONLY Application Accepted by t & a Date r' ` ' S Am Pit or Grout Inspection by U Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Bax 2009, Stkn, CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. INFO CASH . 11111 1: i,xmt .ov I zZ VV1 q- 1.15 EN ta.Ie