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APPLICATION SAN '.-rdAQUIN COUNTY PUBLIC HEALTH YERVICES 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 1s 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 Services. 'Je. Job Address 6da4.1^ `JtY4c)^ ` 4 City Yfi14YLO'^ Lot Size/Acreage Owner's Name W/41s gt.�o $uN/C Address 333 S. �Iz,,.c�/�t/e.� Sf.v.70p phone Contractor T �^0 Address32i7 2•+d S4_�to,Cf3 Sf_417 License No. _7a f6 S Phone 9/C-734-3733 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑/Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ro Monitoring well ❑ �Jitr-00�rabt 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 JUQ C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1'1 Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications f"1 Public f:l Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ State Work Done_ 1 41 If Well Destruction ❑ Well Diameter Sealing Material i Depth _ Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call r arrZinsctions. Complete drawing on reverse side. Signed X_ L�y✓`�Gc2� Title: �ti✓1yJh.�..�.f.t� rryltG(S A't"12''��Date: /f C/6 Bui(d�* q 4VIAt *r-Cs 5-ze Sf�-tr S!; s=f F R DEPARTMENT USE ONLY Application Accepted G,4 S�zv3 Date �T' Area 2 Pit or Grout Inspection by DateFinal Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT NO. Page I3A EN1U.•2E 24(REV. EM riMsr