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Y 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 vork 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. O_500 .�Tr1 Zo -2-- Job Address � � PTDrr�� City�l`Y.FI- ��Mt1t(' Lot Size/Acreage ZO �ff��s Owner's Name CF-0,00-r- CJdr�1S5TLr�T(Uf`r Address 9.0 &k 15) !J'T '7v�' 64 5ZOI Lf750 � Phone ZO $Z.� r' Qpr,t ft c-02VaVi+ Contractor TbF_WjL(-lN(,0 Address-;K663 07oiZQRcbE Gl,c4S7s4ZLicenseNo. 5IC 42- Phone ti<+ C TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT [l DESTRUCTION n Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 7/OV SEWER LINES >t CO DISPOSAL FLD.7400 PROP. LINE >Sa FOUNDATION 7AOy AGRICULTURE WELL ?LO OTHER WELL_LOQ_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation h + Dia. of Well Casing 3 trx.H ❑ Domestic/Private ❑ Gravel Pack orTracy Type of Casing_! C_N. 40 PJ t. Specifications Zl oa rr 5"rs 4cfewri I'1 Public ft Other fl Delta Depth of Grout Seal = Type of Grout CCAP BENPN T£ I I Irrigation q_0 Approx. Depth I I Eastern Surface Seal Installed by dV/yl.t./1GE AJAI'l41 /SSIX-, Repair Work Done ❑ Type of Pump H.P. ___ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth 2 OEU-5 - Wr=C, Depth Filler Material i Depth ( &orfn rl6- ZS f�T- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other p Number of living units: _ Number of bedrooms l� Character of wil to a depth of 3 feet: Water table depth O SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal \.t,\ 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 Q SEEPAGE PITS 11 Depth Sire Number !v 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 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 mmuusstt[yaa fJorr rrequired inspections. Complete drawing on reverse side. ICU 0I_ b Signed X ✓ �/"r Title: 5"/-AF I- L�i�6r/� �� Date: ( `� S nr ^01-sr Fort, 6Aitt"TE CONS-FP17014 �.• w �� FOR DEPARTMENT USE ONLY 2(� Application Accepted by Date Date - Area ..t�' L .Q'P Pit or Grout Inspection by 1 Data Final Inspection by Date Additional Comments: r� u.�lt&/dw42 /oy)f #? t, -wp 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 u-3 `6 NFEE FO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BVDATE PERMIT NO. ,I Y{7L 4 • FEH M II.yA IREV.1/x51 8� �(�_ ,1�(S ,NYU Ill0 ll/ DV�/3.7