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{ U APPLICATION i� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION;j 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388,STOCKTON,CA 95201-0388 € ERYIT EXPIRES 1 YEAR FROM 1DAT2 ISSUED ENVIRONMENTALHEALT (Complete in Trip li date);', PERMSTISERViCES ,Ic 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 i Joaquin County Development Title Section 9-1110.3 and Sectian 9-1115.3 and the Rules and Regulations of Sa h Joaquin County Public health Services. Job Address City r]11P� Lot Size/Acreage Owner's Name Cehlua Address et M Phone G ' f1 {r/a) Contractor Addressljdl CAf .r<_ Ucense. ND...: Phone TYPE OF WELL/P MP: 4 NEW WELL ❑ WELL REPLACEMENT Cl !L DESTRUCTION ❑ Out of service well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ��p�,Q ni bay"' nygWell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J 1 FOUNDATION AGRICULTURE WELL -:'OTHER'WELL PITS/SUMPS _-._ V Se�.l yon �Yir�lf� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS a S y Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casin- Cl Domestic/Private ® Gravel Pack L3 Tracy Type of Casing_ } Specifications I'1 Public 1-1 Other n Delta Depth of Grout Seal i �5�3 CTS) Type of Grout I I Irrigation _Approx. Depth t I Eastern Surface Seal Installs' by 1 Repair Work Done Q Type of Pump H.P. State:Work Dont_ Well Destruction' O Well Diameter Sealltrg Material i Depth II. �+ '�1/,{{fAr Depth _ Filler Material IL Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION ! I DESTRUCTION i I I(No septic system permitted if public sewer is 00' 1 4vailable within 200 feet.) ' installation will serve: Resid Commercial_ Other ; l Number of living units. Number of bedrooms w, Character of soil to pth of 3 feet: �' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ 1 PKG. TREAT NT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation I I Property Line LEACHING LINE ❑ 11 Length of lines i Total Is FILTER BED Distance to nearest: Well Founoation ilProperty Line i{, 1 SEEPAGE PITS I I Depth Size l Number SUMPS L1 Distance to nearest: Well Foundation I� :'IProperty, Line l� > DISPO L PONDS O I 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 Colony it ¢ Home owner or licensed agent's signature certifies the following: "I certify that in the pe{formance 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 subcontracting signature 4. certifies the following: "I certify that in the performance of the work for which this permit is issuedLhall employ persons subject to workman's compensa- r.. tion laws of California." }The�appficanmust for all required inspections. Complete drawing on verse side. ms' K � 1 i� 6 Sr ` Title: Date 1 4i DEPART T USE ONLY 'qr Application Accepted by f Date + Area Pit or Grout inspection by Date Find Inspection by Date Additional Comments: _ Applicant - Return all copies to: San Joaquin County Public Health Services ff Environmental Health Permit/Services I C 445 N.San Joaquin,P.O.Box 368,Stockton,CA 95201-0388 9ZCK if r a^ f { lFEEO AMOUNT DUE AMOUNT REMITTED `CASH RECEIVED BY DATE PERMIT'N0. ci EMr3.241REv.I Asi tM 14' y J