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I` APPLICATION SAN J AQUIN COUNTY PUBLIC HEALTH SERVICES " ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Service,.Jy/je Job Address //^5t�, r'% ,,pp��fj r� r� City/C/ �Q?} Lot Size/Acreage Q F / Q� JQmrLS . M' �� .S OArEes /� 9, Y L7�C / ✓J PhoneU�U -Y��O Owner's Name / y� �' ./_ 073-60�/ - Contractor _Adtlres /4�✓ O ' G License `f Phone�V+ Z TYPE OF-WELL/P MP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION t of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Bell DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION t AGRICULTURE WELL "-- OTHER WELL PITS/SUMPS � �. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z11 ❑ industrial ❑ Open Bottom Manteca Dia. of Well Excavation15 Dia. of Well Casing 31 [I Domestic/Private jKGravel Pack El Tracy - Type of Casing_ Z -- PVC 1 Specifications 1 I'I Public fl Other fl Delta Depth of Grout Sea Type of Grout /40 GOmO.T 1I? 11 Irrigation _.Approx. Depth I I Eastern Surface Seal installed by. ( - Repair Work Done U Type of Pump H.P. State W rk Done Well Destruction X Well Diame5111 ter err P✓�- Sealing Materiel h f Depth 3jU T/- - Filler Material 6 Depth r� TYPE OF SEPTIC RK: NEW INSTALLATION I I REPAIR/ADDITION 1.1 DESTRUCTION I I INo septic system permitted if public sewer is j available within 200 feet.) ]' In allation wil me: Residence_ Commercial Other iS Nu or of 1' rng units: _ Number of bedrooms i •Chara er f soil to a depth of 3 feet: Water table depth L SEPTIC T K. ❑ Type/Mfg Capacity No. Compartments {{f PKG. EAT NT PLT. ❑ - Method of Disposal - Distance to nearest: Well Foundation Property Line LEA ING 9111E 0 No. 6 Length of lines Total length/size FILTER Cl Distance to nearest: Well Foundation Property Line SE AGE P S 11 Depth Size - _ Number SUMP - LI Distance.to nearest: Well Foundation Property Line DISP AL DS O 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 f. 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 fo owing: "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 -,,,torn),." The applican sttcall fof I require inspe, ns. Complete drawin o everse side. r io I Signed X ' '� Title!'1 ' fi ❑ Date: -� 4 1 FOR DEP RTMENT USE ONLY - Application Accepted by Date 7 31 IS Area q Pit or Grout Inspection by Date `� 31 �� Final Inspection by v - �" Dote Additional Comments: Applicant - Return all copies to: San Joaquin County Pahl Health Services �� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. { 1 `y'-7 . EH I3-74 IREV.11.51 W O V 17 EH 1,