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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 . Job Address t `7T 5 lv f S n LI 4n City 7 L Lot Size/)Acreage Owner's Name S I CLL19 �V IC'IHAJ4r✓ Address � Q "JX � , 7/��Cli , / -� Til Phone )401 NAl.; i D Contractor /�� GrJ ,i (✓? TFF J <: Lfkyu/L<yAddress I1CST 1 cr Hrry E�� rr 61 LicenceNo. `'� h �Er�i Phone / r' � � �� 100 TYPE OF WELL/ PUMP : NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well lr DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD . PROP. LINE �l FOUNDATION AGRICULTURE WELL OTHER WELL PITS / SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia . of Well Excavation —/A/ CA4 Dia . of Well Casing ZWc/t ❑ Domestic/ Private KGravel Pack ❑ Tracy Type of Casing I' ✓L —Sc Kyai 40 Specifications L " a 20 I 'I Public fl Other fl Delta Depth of Grout Seal e — / Type of GrouIA1jL*T CC—Alae/]' 11 Irrigation _ Approx , Depth I I Eastern Surface Seal Installed by S6 / LJ EY /)Lnf(ir-Y/OBJ J'FR II/«`1' Repair Work Done ❑ Type of Pump H . P , °•'eft State Work Done Well Destruction ❑ Well Diameter —rI ✓cfi Sealing Material i Depth 1$14f k/ > d ' — / L3E4 -0N / 7T Depth % O r-f(' 7 Filler Material a Depth 0-3 S .RND '—`-� 3 � — 2-0 ' 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 feetA Installation will serve: Residence _ Commercial _ 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. ❑ - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. 8 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 ❑ 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 atoll not employ any person in such manner as to become subject to workmen's compensation laws of California . " Contractor's hiring or sub-contracting signature certifies the following: "I cenity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenu. tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. , le Signed X . -�7 ,_ " Title: r1'OC /A i 1 Glt`O�gGr,,P i Date: FOR DEPARTMENT USE ONLY Application Accepted by 3fi y) ' Date �' � If ��' Area t` T f � Pit or Grout Inspection by Date Final Inspection by Date Additional Comments Applicant - Return all copies to : San Joaquin County Public Health Services �� D Environmental Health Permit/Services 445 N San Joaquin , P O Box 2009 , Stkn , CA 95201 if INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 1324 (REV. 1 re EH 14 2si d ' Gy c (` e