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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION E_ 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 cc 001, ' 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 /Sr �7 F-,�+'�+1(�1 i?- 9-n mak City_T 9 Lot Size/Acreage •�G / d-C✓'L Owner's Name 11 �C t1-S'Tt M fr 041 f Y� Address P 0, Q C k,9 1(= ��P rtQ O (l ,I7A Phone 7C-7 —4= - Contractor`f, heSl(AhCt1-�: " Address I(7S42rnPC Qic/d, qrt LICenSP No. K25!5461 Phone - - 6C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7 DESTRUCTION ❑ Out of Service Well ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR O .0op,INE S 0Z4E-R Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 7 /a= l SEWER LINES DISPOSAL FLO.>/00 r PROP. LINE '<y- FOUNDATION _sFOUNDATION L-50 r AGRICULTURE WELL OTHER WELL� �C� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS c-- I-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 14 Dia. of Well Casing roc n Domestic/Private ❑ Gravel Pack ,Tracy Type of Casing_ A10.-)E Specifications 11 Public (.1 Other 171 Delta Depth of Grout Seal A-L 4- Type of Grout Na OT CEM.GNr (tom I I Irrigation -2 Approx. Depth I I Eastern Surface Soul Installed by CSM W")7— Repair Work Done U Type of Pump N H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth rV ZAI- CZmEAir y 20 El Depth -7 / Filler Material i Depth 2�(j TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION 1 I (No 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 soil to a depth of 3 feet: Water table �!a t//�� ,�+ SEPTIC TANK ❑ Type/Mfg Capacity No. Compa l" PKG. TREATMENT PLT. ❑ Method of fiifpea2 4 1993 —51 Distance to nearest: Well Foundation Property LineSANJOAQUIN COUNTY J LEACHING LINE ❑ No. At 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 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, 1 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: '•1 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 all required inspections. Complete drawing on reverse side. Signed X �(��i -- Title: 0.1' IOAele.7L'AU V,-5/CS Date: -2 F 41-,0 r-6,S,AVJ c.V V1401VIn9✓I-A— CrcNS•� 'S FOR DEP RTMENT USE ONLY Application Accepted by " Date �24 Area 3S Pit or Grout Inspection by Date Final Inspection boidle Date/ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT Oht1/E� AMOUNT REMITTED CASH R�EC%E/IVED BY r/� DATE PERMIT'NO. 14.21111fV.rin St �+ f�(JV � VI /1 SqS 3 �J ,..ze 11