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�at� l►�o-i2'•"� APPLICATION S, N ,� : w .- s . s c v � � : - nnd µ,id 31�i` AN JOAQUIN COUNTY PUBLIC HE T VICES rj,�U� ENVIRONMENTAL HEALTH DI I 445 N SAN JOAQUIN, PHONE (20 )e#4420 ��.-� � P O BOX 2009, STOCKTON , C _lA'`' ,�} ;2 ��J `, PERMIT E%P I RES 1 YEAR FROM D ANM SCJ (Complete in Triplicat 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 Services. _21 3t i JoAddress `City&J�y 70 'e-4 Lot Size/A/creage37-i Sr� ci S►iAddressOwner's Name�% ` Contractor.Z/ e2l /'/ w'fA c �f (Address 4S S/ 5 1"f/ �G �C License NoC-S7 % Phone-�53- TYPE OF WELL/PUMP: NEW WELL f- WELL REPLACEMENT F1 DESTRUCTION Cl out of Service Well ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. �P.�R--OP. LINE FOUNDATION T 5 �� AGRICULTURE WELL OTHER WELL e2 r SPITS/SUMPS INTENDED USE Ll Industrial Cl D,grKesticlPrivate I ublic I I Irrigation Repair Work Done v Well Destruction O TYPE OF WELL ❑ Open Bottom V caravel Pack 11 Other Approx. Depth Type of Pump _ W II Diameter PR BLEMAREA CONSTRUCTION SPECIFICATIONS Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Tracy Type of Casing___ S'r%� Specifications Il Delta Depth of Grout Seal /Uy Type of Grout I I Eastern Surface Seal Installed by 7-2" Z n/CfF� sfj1 ` "L' H.P. State Work Done _ e Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Otlter Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well8t c'r' Foundation 6 - s ~ Pro�ylty/s� I a 1`' MENT LEACHING LINE Cl No. & Length of lines Total long FILTER BED Cl Distance to nearest: Well Foundation PMIARY Ling( ^1111 SEEPAGE PITS I I Depth Size ` Np lbr P IN COUNTY SERVICES SUMPS 1-1 Distance to nearest: Well Foundation ENVIR L%tf4ti Vi DISPOSAL PONDS ❑N 1 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." Contractor's hiring or sub -contracting signature certifies the following: "I cenify 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." The applicant cast call for all wired inspections. Complete drawing on reverse side. Signed X Title: �C`'X7L. Date: FOR DEPARTMENT USE ONLY r Application Accepted by \�_LC —J� i Date Pit or Grout Inspection by U Date Final Inspection by Additional Comments: �� """ 1 ``✓-1 FT�,�;; r �'� ��y Applicant - Return all copies to EH 1 -24 (REV. rixs) EH 14.26 Area i Date /a71 San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 Of � fir/[ %u rl� Cq FEE 1 AMOUNT DUE A OUNT REMITTED RECEIVED BY DATE PERMIT NO. e? aw- aw-