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APPLICATION JOAQUIN COUNTY PUBLIC HSA SERVICES ENVIRONMENTAL HEALTH DIV1,iION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Ben Joaquin County for a Permit to construct and/or install the vork herein described. This application is aside in compliance vith San Joaquin Co4rity Ordinance No. 549 and 1862 and the Rules and Re Joaquin County Public Health Servlcpp Regulations of Sea VL�L . 1 Job Address �61`T `, F STcci<Tor.1 t city ST�'+<K TW Lot Size/Acreage Owner's Name �dz-T oa= S-c�cK To� Address ZZ.CA LJ `J AS"iw Cr,TUN Ph.(ZC-1 946 024C- PO 24E Po CA 9SES'y- Contractor VdAie2 Address 1202 re.JT,ICIc AUE esu- / y License No. ze.az.6 Phone6i 664 zezy TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 SPECIFICATI NS s,�s-� =a .� rncNe� TACIT I�, Cl —Industrial !❑,,Open Bottom ❑ Manteca Die. of Well Excavation _ Ou. of Well Casing Z 11 Domesim/Private ,ry Gravel Pact ❑ Tracy Type of Casing hV C— Specifications Scg 4G i'I Public 17 Other XDelta Depth of Grout Seal Type of Grout Ce^'-^'T S.t bre`f 11 Inigauon _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. ._. State Work Done _ Well Destruction ❑ Wall Diansur _ Sealing IYteriai i Depth Depth filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) Installation will sane: Residence_ Commercial_ Other Number of Irving units: _ Number of bedrooms Character of sort to a depth of 3 fest: Water table depth/ SEPTIC TANK ❑ Type/Mfg Capacity No. Comoartrtlente PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines - Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sias Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Home owner or licensed agent's signature cenifies the following: "I cenify that in the performance of the work for which the permit is issued, I Mall 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 conlponsa. tion laws of California." The applicant must;"Ali lot all tsquired inspections. Complete drawing on reverts side. Signed X /aN� C�1 cmc 1 ASS, Title: C- t,-T Date•. Z�2/c�Q. 3111 D ARTMENT USE ONLY Q Application Accepted by �- h.L�U '✓� _ Date - Area Pit or Grout Inspection b �" ! (� � .3 Y � Dans - Final Inspection DY 17)� '��- C11�1 Dau 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED Sy DATE PERMIT NO. NFO CASN • EN 13 24 IREV,ve 51 Q r" 110191 Al�3