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LAyhAc APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ ,Uo SSE ��,eESS (Complete in Triplicate) 3 Sores $ol�, ,S Application is hereby strsde 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. .Sa 'X 3S'' -ZCv"Ft 4D MA7j71ffY SAO g Job Address Hrutiy 4.006 gLVO C,ty �Aw Lot Size/Acreage �Oy/Q�RCrS PGtb C-uSS�Ppt ' j, �! s % _Q �1In,� 10 Owner's Name Y leu s i mess ti n� ` Address I V Phone xL I SC_ T-e5+ice (Ilan iAe� C�C�� Contract ec Addr€ s S0 1 License No.q�JLtO� Phone / - 1 TYPE OF WETUPU P NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION C SYSTEM REPAIR C OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing 171 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications I'1 Public I-1 Other 1-1 Delta Depth of Grout Seal Type of Grout 11 IrriOatron _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Dorm U Type of Pump H P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION i i DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) Installation win serve: Residence_ Commercial .— Other Number of kvwV units: Number of bedrooms Character of wit 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/lf1A C) No. & Length of lines Total length/size FILTER BED ' n Distance to nearest: Well Founoatwn Property Line SEEPAGE PITS k)/,4 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 regulatwro of the San Joaquin County Home owner or licensed agent's signature oertifies the following: "I certify that in the performance of the work for which this permit is issued, I shag 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(olowing: "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 ilomia." The applicant t II for an r inspections. Complete drawing on reverse side. -} i� p Signed Title: �/'t'��-['�;PG1'L141S/ Date: FOR DEPARTMENT USE ONLY Application Accepted by - Date / Zs / Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. Pale 13A EN t}2�111EV.r i m sr n fH 14-38Q �' I .� U�