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APPLICATION .+... SAN AQUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN', PHONE (209)468-3420 P' O BOX2009, STOCKTON, CA 95201 { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED q pp�� 1` 1 2 I (Complete inTriplicate) Zldb+`[✓� JS -to w1 1 CSOrt/lG4c, .!Q -7cohVfN++O - I Application is hereby made,to San Joaquin County for a perms to construct and/or install the vork herein described. This 1 application is made in compliance with San Joaquin County Ordinance No. 51+4 and 1862 and the Rules and Regulations of San Joaquin Courtty,Public Health Services. { {a City �p 6+0 6 Lot Size/Acreage �S �e"'fs I fJob Address _ `4 � P.Q,( DX,©S �c Q(� p 9 k dU] 535 Phone. D ! 1- 2q Owner's Name�N ty I eV�).to01a s Address 7-Gt� � { _ l rilllj'OflntC�a1 �Q. Contractor f I Address AD f3oZ7-31,k.AetiaCd1arav4 License No.6 7.Z( -,Phone gs�' TYPE OF WELLlPUMP: N W WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service We f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Z 60/11x1 THER Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7 /QD, DISPOSAL FLD. A)14 PROP. LINE SO FOUNDATION AGRICULTURE WELL �a OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I f [I.Industrial ❑ Open Bottom D Manteca Dia, of Well Excavation tl Dia. of Well Casing Se_0een' Domestic/Private MW ❑ Gravel Pack 0 Tracy Type of Casing_SG� © y C Specifications J I'1 Public rel Other 1-1 Delta .Depth of;Grout Seal _�1 -- Type of Grout IUIF1*2 7e�ff t I i irrigation ,fApprox. Depth Eastern Surface Seal Installed by late eCo-fF-6ameaAW t k Repair Work Done L3 Type.9f Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material •& Depth Depth Filler_Matertal & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRrADDITION I ! DESTRUCTION I I (No septic system permitted if public sewer is iavailable within 200 feet.l PInstallation 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 , 0 No. & Length of lines Total length/size r 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 ❑ 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 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 eritploy persons subject to workman's compensa- tion taws of California." The applicant must call for a requir d inspections. Complete drawing on reverse std . Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Data Area r Pit or Grout Inspection by Date Final Inspection by Date } .Additional Comments: r C Applicant - Return_ all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services A 445.N San Joaquin, P-0 Box 2009, Stknr CA 95201 FEE{ INFO AMOUNT DUE AMOUNT REy/(M�ITTtO CAS�H{/ RECEIVED BY OATS+ PERMIT'NO.. Page 173A i EN 124 IRE4,r/n 51 EM 4.20 3L