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APPLICATION SAN JOAQUIN 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 . J Job Address t{ D �l Wei4� F✓ en*k, ori CityG. Ick elliI Lot Size/Acreage -?/y L4FC w Owner's Name jCr, !gf & I// C ✓2t1YN QU �Q V Address 1 :70140 frtt+C r2QTf Sqc ✓¢as e&t ftfO Phone Contractors Address License No . CC ? C� 1pgPhone TYPE OF WELL / PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well kv DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO . PROP . LINE FOUNDATION >> ro. , AGRICULTURE WELL OTHER WELL PITS/ SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation J.O Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing P L Specifications I�[L PI tic q ❑ Other Ll Delta Depth of Grout Seal 219 , Type of Grout cei"esr/-Bemk lfe II irrigation�Or aKJ _ Approx. Depth I I Eastern Surface Seat Installed by /ESTEJC Repair Work Done ❑ Type of Pump H , P . State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK : NEW INSTALLATION I I REPAIR /ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet. ) Installation will some: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of edit to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/ Mfg - Capacity. No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 cenifies 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 subcontracting 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 applicant must call for �alllrregquuired inspections. Complete drawing on reverse side. Signed X 729:✓ •-er.i[- /Y v....-� Title: s_- j pr61 LE Data: n FO EPAflT ENT USE ONLY Application Accepted by d\) (, Date Area Pit or Grout Inspection by � Date Final Inspection by Date Additional Comments: 1� OfP, //KJ72//J� Applicant - Return all copies to : San Joaquin CountyubP lic Health Services 3 t 0 Environmental Health Permit/Services CU' 445 N San Joaquin , P 0 Box 2009 , Stkn , CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO C K RECEIVED BY DATE PERMIT ' NO. EH 13-24 (REV. r / ner / X �5 t OD 3as$ EH 14.20 U ✓ ••//