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APPLICATIONx SAN(.,i!AQUIN COUNTY PUBLIC HEALTHt.;RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Sery can. G Job Address //� /T� UA1/ ©� City//S7 r�/ Wt Size/Acreage l / / Address Al ,v '5*" Phone 767 �/v Owner's Name 7 C ,p /n{�(, �p 7 y Contractor DC// �� j Address/ y� '�"i� / �7 /r31c'/ Lice�e N 2'3/Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 0ESTRUCTION J<0u of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTH Monitoring Nell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications CI Public I1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Stat W r D no N� Well Destruction Well Diameter Ira 1, 1 1 Sealing Material i Depth 0135D I Depth 354 Filler Material L Depth 4 3E6'1/Jgt�,,,�Vr74y1� PE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADOtTION 1 I DESTRUCTION I I INo septic system permitted it public sewer i available within 200 feet.) Insta ion will serve: Residence_ Commercial _ Other Number ivinp unite: _ Number of bedrooms Character of . to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments C PKG. TREATMENT PLT. ❑ Method of Dispose Orate nearer all - Foundation Property Line � LEACHING LINE ❑ Length of lines Total length/size FILTER BED Distance to nearest: We Foundation Property Lina t SEEPAG ITS 11 Depth Sire Number SU S Ll Distance to nearest: Well Foundation POSAL 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 workmen's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I ertify 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 Cslifomj�ajThe ap➢lica us or all r i e i ti Complete drawing reverse si Signed�kL i S ✓'fin-/ Title: 0. �j� Data: FOR DEPARTMENT USE ONLY Application Accepted by Date "-'' �O' Area Urt IQ+_ Pit or Grout Inspection by atelj-t�E� F' Zino by Oats q Additional Comments:. Applicant - Return all copies to: San Joaquin County Public Health Services 5T f Environmental Health Permit/Services l 445 N San Joaquin, P O Boz 2009, Stkn, CA 95201 AMOUNT DUE AMOUNT REMITTED . CLA1H RECEIVED BY DATE PERMIIT'^NO. • EM I}3x IaEV.rr.ar1,61NFIO � Q.1 DO - CETLLq EM tx.1a Wim/