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' APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES — ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 1n 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 is compliance with San Joaquin County Ordinance No 5119 and 1862 and the Rules and Regulations of San Joaquin Caun Public Health Services. 4 C9-"tS71tL)GT=�0H Job Address -�17- M*��ST Rx&,t_ Q=y City 7bt.i�ot-� Lot Size/Acre e 1 ' Owners Name i''�. 00.&-Re Y84 L bs - Address-1-1Z. " ' � SPhone 2 g ro Contractor Jk&&JA6 4-ASSOC- Address17-3 COwwt�t'e C7: License N04ffl0e Phone f ' TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER % Monitoring Well ❑ DISTANCE TO NEAREST SEPTIC TANK H th— SEWER LINES DISPOSAL FLD PROP LINEE`" acRzt^{G- ' FOUNDATION Z+St AGRICULTURE WELL OTHER WELL PITS/SUMPS l` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Ia industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Of Dia of Well Casing ' F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I 1 Public I Other o 4„ I1 Delta Depth of Grout Seat 1201 Type of Grout 1 1 Irrigation Z!Z Approx Depth I I Eastern Surface Seal Installed by 1<2ka-41-1 Repair Worts Done L] Type of Pump H P State Work Done_ ' Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I I (No septic system permitted of public sewer is available within 200 lest ! 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 ❑ No $ Length of fines Total length/size FILTER BED ❑ Distance to nearest Well Founaation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS Li Distance to nearest Well Foundation Property Line I DISPOSAL PONDS ❑ 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 shalt 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 follotiving I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman s cornpensa tan laws of California" The applican roust for ail required inspections Complete drawing on reverse side/,, _ Signed Title �7oIL L.blr�r i Date IZ So FOR DEPARTMENT USE ONLY Apphcano Us— by Date f� ` s+ Area Q Pit or Grout Irtspection by/ Date i _ Final Inspection by Oats f 6Addnional Comments �• it+st Applicant - Return all copies to San Joaquin County Public Health Services Environmental Healtb Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 I INFO AMOUNT DUE AMOUNT REM1TTl D CASH RECEIVED 9Y DATE PERMIT NO Page l e TSA EH 13-24 IREV ti i 51 L t�