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APPLICATION `- t ' ihUIN COUNTY.PUBLIC HEALTH SERVICES SAN AQ ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009,,'STOCKTON, CA 95201 PERMIT EXPIRES 11YEAR FROM DATE ISSUED ,. 4 (Complete in Triplicate) I Application. is hereby made to San Joaquin County fora permit to construct and/or Install the Wvrk>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 Services. i 1 6 Job Address 1$7 tV�GJv�n�o,n �ac 1 _ City !ke.twT0vk _ Lot Size/Acreage _ 1 Owner's Name T S- ag�0 CVG Address '95 1-5 11 re n o rc. J Phone -$S 7 i i I q4 CEke Contractor F Address�bL3 C�lwef 4 C,,cle.C��dauG. License No. S L9`(2-V Phone I L6^ fil•g� TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t+ ❑ Industrial ❑ Open Bottom [1 Manteca Dia. of Well Excavation 1v+ • Dia. of Well Casing l Domestic/Private Cl Gravel Pack L7 TracyType of Casing_ ?VC SCI, . 40 Specifications (1 . r ��,,�- 1"1 Public l Other n Delta Depth of Grout Seal r Xe 5 Type of Grout Wday Lem 11 trrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump kVA— H.P. MIA -- State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth r_ Depth Filler Material i Depth 4-1w GJC1' __ ✓11l TYPE OF SE WORK: NEW INSTALLATION I 1 REPAMR ADOITION I I DESTRUCTION o septic system permitted if public sewer is 11 available within 200 feet,I 11 Installation will serve. Residence_ Commercial_ Other ' Number of living units: Number of bedrooms v` 1 g Character of soil to a depth o feet: tyf SEPTIC TANK. Will ❑ Typal Capacity rtn Ill TREATMENT PLT. ❑ t �1�• Distance to of ell Foundation Prop"Vneft-1,1902 I. LEACHING LINE ❑ No. & Lengt f lines 1 TotalRWfabr6 FILTER BED ❑ Distan o nearest: Well 1 Foundation ENV P4QvpeeHFp�Tra510f SEEPAGE PITS Depth Size Number { SUMPS 1 1 Distance to nearest: Well Foundation Property Lina DISPOSAL P S ❑ { 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 I 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." I The applicant must call for ail req di s. Complete drawing on reverse side. II I j Signed �- r Title: -5-4�s.�+r� �r'Go �o f' + s: Date: 112- 14 FOR DEPARTMENT USE ONLY y ' Application Accepted by Date Area PR or Grout inspection by Date Final Inspection by Date - 1 Additional Comments: Applicant - Return all copies to: Salt Joaquin County Public Health Services Environmental Health Permit/Services d 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. . EH 13-241ACV.lin S! , { EH 14.76