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APPLICATION SAN em AQUIN COUNTY PUBLIC HEAILTH RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 u - PERMIT SIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Appllentlon is hereby made 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. 5149 and 1662 snd the Rules and Regulations of San Joaquin County Public Health Services. --� Sd� ti0E�3 �C L 20t+� l%1Z.N 150,Lot Size/Acreage Job Address _ City Q Owner's Name Address 541",E Phone ! 0 D S n 95o Mows AoA-b 9915-573 Contractor Address IYI,+41Z /U license No.�LslCos Phone 3/3 ` std TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl. DESTRUCTION Q Ou ❑ PUMP INSTALLATION 13 SYSTEM REPAIR O Monitoring N OTHER ❑ ell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD�� `. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PtTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a le M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -- ---- Cl Domestic/Private �iravel Pack El Tracy � Type of Casing— VG Specifications 2•Q - - -- I IPublic 1:1 OtherCOea Depth of Graut Seal rir t NL�T'� CG I I Irrigation 35 Approx. Depth I I Eastern Surface Seal Installed by 14G£ Repair Work Done L7 Type of Pump H.P. State Work Done a r Sealing VAterial i Depth P' A—T Ct Fa f wT 0 /4PAou� Woll Destruction ❑ Wel! Diameter �} �RppRolc� Depth 3S� Filler Material i Depth a S/frv0 /O,' 35� TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRIADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.), Installation will serve: Residence— Commercial T Other !Number of living units: Number of bedrooms ° Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' .Ih LEACHING LINE ❑ No. S Length of lines Total length/size -FILTER SED ❑ Distance to nearest: Well Founaation Property Line ' SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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, find 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 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 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 compente- tion laws of California." The applica u t ca for fired inspections. Comptate'drawing on reverse side. Signed Title: pao T rG r Al AN 4-cy-4le- Date: FOR DEPARTf1RENT USE ONLY - Application Accepted by Date r Area0 Pit or Grout Inspection by Date Final Inspection by Date )Additional Comments Applicant - Eteturn all copies to: San Joaquin County Public Health Services w Environmental Health Permit/Services T " r' 445 N San Joaquin, P 0 Box 2009, Stkn, CA..95201 FEE AMOVNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. • EH 13-244 INFO page 131 tREV. /p Sl I ! Y f YY `-' •(/�J t ��t,I fM tt-2a