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6 APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALH ICES Q � ENVIRONMENTAL HEALTH DIV S 445 N SAN JOAQUIN, PHONE (209 20 P O BOX 2009, STOCKTON, CA PERMIT EXPIRES :L YEAR FROM D (Complete in Triplicat 'IN'I Application is hereby made to San Joaquin County for a permit to construct and �V 1 application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �y.. Job Address y,S�wtT�"' ""H �� City srO`��00n Lot Size/Acreage 3� Owner's NameCLeyrM TccA A/odyiTCAddress k�o H`IKD Ra-wbo.-0Sa a kaftrPhone t r.c�vl1ef�%' e- o ?° .l-'y Contractor SO,-/5- E / /,' aes' 3 . /57-`.2/3Ydsf55 ` TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION L) Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 3 .So /&'l-RTHER-,2_' Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6o feel- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation I,. Dia. of Well Casing Domestic/ rival ❑ Gravel Pack ❑ Tracy Type of Casing Tc,k- Y® 1 �- Specifications 1"I Public 7csT1..E l/ Other/nowbe-,P� n Delta Depth of Grout Seal sJ2-70 " OFS Type of Grout Nw2rC04064X I I Irrigation ,$b�$rApprox. Depth I I Eastern Surface Seal Installed by tr / u v ce3 rr c. Repair Work Done U Type of Pump H.P. State Work Donww. .,rbr-r" Well Destruction O Well Diameter Z Sealing Material A Depth 41. -p i` e N C a29fT; (I) Depth .10 fr Filler Material i Depth Ar3 SaAv J_ - D To�I 'r *3 X04 rr, s 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 serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soft to a depth of 3 fest: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Met Distance to nearest: Well Foundation Property Li LEACHING LINE ❑ No. b Length of lines Total length/size_ 1lQV 9 Q �11QQ. FILTER BED ❑ Distance to nearest: Well Foundation Property Line HEALTH SEEPAGE PITS 11 Depth Size Number Gly i.- PERMITISOVICES SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 Horth 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 workmen'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 lawn of California." The applicant must call for aR required inspections. Complete drawing on reverse side. Signed X ,& �� Title: Ck Ja-;.�'j� Date: 1�_ FOR DEPARTMENT USE ONLY �{ 315 .O I Application Accepted bji /�� Dots ° v ° Area 1 Pit or Grout Inspection by Date1 Final Inspection by Date Additional Comments: COrre.G� 1dCZ�LD✓\�j :35 pj +- I MW 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'N0. . EM 13-24 IREV.1rn 6lX - '}� f[,t�� 00/6?GI' E"14-as VVV