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APPLICATION -- - - t SR # SAN:. JOAQUIN COUNTY PUBLIC HEALTH EERkgI S ENVIRONMENTAL HEALTH DIVISI1111UU k 445 N SAN JOAQUIN, PHONE (209)4 8- 2 P O BOX 2009, STOCKTON, CA 9 PERMIT EXPIRES 1 YEAR FR : DATE A (Complete in Triplicate) V 8 {. Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This r application is made in compliance with Ban Joaquin County Ordinance No. 51+9 and i862 and the Rules and Regulations of San Joaquin County Public Health Services. { a �i .4 Job Address 2 2� 1 City D Lot Size/Acreage Owner's Name 1I� �t�tn� ,,.Jf�✓✓Dress Zz Phone lha Coral i' C-5 (9/!0 [� Contractor l rrt1 lid Address 40 t3OY ZZ 1 CA '75741 License No. �1�Phone 52- 553 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M I DESTRUCTION ❑ Out of Service Well �7 PUMP INSTALLATION L3 SYSTEM REPAIR C7 OTHER V, Monnito Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES #DISPOSAL FLO. PROP. LINE S FOUNDATION AGRICULTURE WELL 11OTHERIf WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2�f t f-7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/Private ❑ Graver Pack L1Tracy Type of Casing ! r->VC _ Specifications C I'1 Public 1-1 Other f I Delta Depth of Grout Sed5 Type of Grout 11 t(rigation ...-...�Approx. Depth .t I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump H.P, Statei{ ork Done Well Destruction ❑ Well Diameter Sealing Material & Depth{ 6 Depth Filler Material & Depth 1 E , TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION.I I DESTRUCTION 11!IlNo septic system permitted if public sewer is i¢ �javailabie within 200 feet.) ! Installation will serve: Residence_ Commercial— Other �' w Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: = WINT �l1 r W: I. SEPTIC TANK ❑ Type/Mfg Capacity - PKG, TREATMENT PLT. 0 Distance to nearest: Well Foundation Property "o ) 7 19 9t itrint INTY I LEACHING LINE ❑ No. & Length of lines j7otal lertgt RVjEF 5,11 FILTER BED n Distance to nearest; Well Foundation �'I cw tY�TH SEEPAGE PITS 11 Depth Size _f Number SUMPS CI Distance to nearest: Well Foundation �} ,Property Line DISPOSAL PONDS ❑ 1r 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 notom} ' 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 compensa- tion laws of California." The applicant st call for fl required ins drawing on rev a side. - r Signed sit /"f r/ Tithe: —, lis/G!c/7! ° Date: s SFOR DEPARTMENT USE ONLY ApplicationAcceptedby ``�f 1�� ii Date Area } Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I i Applicant - Return all copies to: San Joaquin County Public Healtklsarvices Environmental Health Permit/Services 445 N San Joaquin,. P O,Box 2009,F"Stkn,j�CA 95201 I. lPEE AyeUNT DUE AMOUNT REMITTED CASH RECEIVED BY i DATE PERMIT�NO. • EH1 3-24 1REY,ti x sl1'2197�5