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APPLICATION SAN JOAQUIN COUNTY PUBLIC H 2L f_Efflr ENVIRONMENTAL HEALTH I NENT 445 N SAN JOAQUIN, PHONE 2048— RECEIVE D1,1 O BOX 2009, STOCKTON A+ 01 PERMIT EXPIRES 1 YEAR FRO SSUED �w�-t (Complete in Tripl tate � � CQt;N7 l;��r PUBLIC HEOALTH SERVICk Application is hereby made to San Joaquin County for a permit to construe s illi n - t application in made in compliance with San Joaquin County Ordinance No 5 u es an egulations of San Joaquin County Public Health Services �I 2. Job Address b Cn City Lot bize/Acreage � � 1 Owners Nama Address OOa0 L r-y-Z-.s 49, Z,Vb • Phone aka' ezz3 t-16 Contractor 'r "vim_Address _Re,.cl�� C� r o a %-AL License No 5-)AN-71 Phon !,(�35- 2 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well ❑ PUMP INSTAL LATEON ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Kell Ar DISTANCE TO NEAREST SEPTIC TANK SEWER LINES 5c r DISPOSAL FLD PROP LINE 145 FOUNDATION + AGRICULTURE WELL AJ-&— OTHER WELL_ PITS/SUMPS LVA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z Cl Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Weil Casing u n Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ,Sssy �d - I I Public I'1 Other n Delta Depth of Grout Seal _�� #' 4*-A Type of Grout C-G I I Irrigation �Approx Depth I I Eastern Surface Seat Installed byiA;2s.�� Repair Work Done 0 Type of Pump e f H P State Work hone W,e1LDestructro i� �A Well Diameter �..� Sealing Material i Depth � l � 4r d 461 `\ X Ivr+� Nb%, _3I Depth GS Q Enr,,ic, Filler Material i Dep t ' W e6141tWi TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet I 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 lines Total length/si:e FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS Cl 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 1 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 sub contracting signature candies 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 must call for all (squired inspections Complete drawing on reverse side Signed Title C� r� 'JGt nGt mer Data -:P _j /ry ' FOR DEPARTMENT USE ONLY Application Accepted by Pate �J Area Pit or Grout Inspection by ,i Date Final Inspection by Data V Additional Comments 3 U t 1AIviS Applicant - Return all copies to San Joaquin County Public Health Services Environmental Health Permit/Services k6 U Ir 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMi7 NO �O INFO EiMi t1�_9L i,wsi IRI? 1139 z'ZZ-� 002,3 z�