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APPLICATION SAN JOAQUIN 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 Joaqu1— 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 !862 and the Rules and Regulaticns of San Joaquin County Public Health Services. \ - Job Address f �/J `l City G Lot Size/Acreage J= °iCt/rs - Owner's Name address 4c P P\c�'� ASF - Phone �Q t C Contractor z �("�� Ac_ress3`t)-i 0! License No.��t�ba.zll Phone ' - l t TYPE OF WELL/PUMP: NEW WELL " WELL REPLACEMENT t:1 DESTRUCTION O Out of Service Well O PUMP INSTALLATI�C�N�� SYSTEM REPAIR E] OTHER G Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK PYA SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 _ rJr'�,c> Dia. of Well Casing F1 Industrial O Open Bottom Manteca Dia. of Welt Excavation _f(_ 9 C, Sc 1, c S PoG Sc-i tf b C.l Domestic/Private O Gravel Pack y Tract/ Type of Casing_ 0 pecificaf�tlyon� I'I Public I 1 Other Delta Depth of Grout Seal Type of Groui I I Irrigation _Approx. Depth i Eastern Surface Sedl Installed by Repair Work Done 13 Type of Pump •�o� r•'t1 H P. VZ 14 P St to Work Done _ ell Destruction O Well Diameter `f J r✓1, Sealing Material & Depth (T NNOA�.t0 C�^ Depth,5n *b=—; Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATICN I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it,public sewer it available within 200 feet.) t'+ Installation will serve: Residence_ Commercial_ Gther Number of living units: Number of becrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Metf EN Distance to nearest= Well Foundation Property ATCEIVED LEACHING LINE Cl No. & Length of Tines Total Length/size .1111 f g--9 FILTER BED O Distance to nearex: Well Foundation Props a ~' r�AL 1PJ v�1 _•jUNJTY ;. p I I o I I oI-�-v�r� SEEPAGE PITS 1 I Depth Size NumbefF11UIR(lNfLtl SUMPS LI Distance to nearest. Well Foundation _ Property Line DISPOSAL PONDS 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 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 01 c to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the folio g: "I ca y that the perf nce of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws o ifo ia." The ap i t 1 c r at ui ins t f,omplet'eJddrrawing on reverse side. SigTitle:7A/?�j�+ lL•�+�S�L, Date: FOR DEPARTMENT USE ONLY Application Accepted by Dace Area Pit or Grout Inspection by Date Z—f `3 Final Inspection by Date `S dditional Comments: Applicant - Return all copies to: San Joa in County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009„Stkn, CA 95201 r { 3 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. t INFO CASH //`.�((�� EH 3-24(REV a- 6 ^`JC/ EH t4-2e