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Ve APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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) Application 1s 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. Job Address w jv C. /�!//V// CIIy,,�]a�— Lot Size/Acreage Owner's Name4 /1 t` ��'6'/`��"'rte AddressX /s (!-Z LLF`� ✓CT Phone �N.� 6 Cf) Contractor W G� ddress Lv—' W. Wq License No, Phone Yl TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 1-1 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION C1 SYSTEM R�PAIR D OTHER 0 Monitoring Well ('f' DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES SD DISPOSAL Fl. N PROP. LINE k FOUNDATION AGRICULTURE WELL &/ OTHER WELL PITS/SUMPS�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 I atrial 0 Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ VUR Specifications 7,� I'I Public 1-1 Other III Delta Depth of Grout Seal 2� Type of Groutl'G6si L41W 1 1 Irrigation —.Approx. Depth Eastern Surface Seal Installed by 4040' Ld£L6. !11li Q` Repair Work Done U Type of Pump H.P. Sisto Work no_ Well Destruction 0 Well Diameter Sealing Material L DepthflAox Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l Insnllatio I serve: Residence_ Commercial_ Other Number of living u Number of bedrooms Character of soil to a depth at: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to near Well oundetion Property Line LEACHING LIN:�.�Dmt,"n ength of lines To th/size FILTER BED e to nearest: Well Foundation Props 'ne SEEPA ITS II Depth Size Number SU PS LI Distance to nearest: Well Foundation Property Line DISPOSAL 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 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 applicant c or all re uired inspectio C Complete drawing on reverse side. Signed Title: IA(I*GT !P( 7✓r/[9`i� Date: FOR DEPARTMENT USE ONLY Application Accepted by �t�'t' ( ��N`-^��.crat — Date 0 ^ Area Pit or Grout Inspection by Date Final Inspection by ' Lr+ to t e Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services r c/ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY //'T DATE PERMIT NO, �' . EH ID-24IREV.r/x51 MOD .Od �� /� �� Z/� EH 1621 __ 1 ,