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� APPLICATION Nk-11 O I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -1D -52.Ac; ENVIRONMENTAL HEALTH DIVISION PH 445 N SAN JOAQUIN, PHONE (209)468-3420 C� f P O BOX 2009, STOCKTON, CA 95201 I 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address yl�' Er.71i�Si^w� CityLot Size/Acreage (A jaJ t l.. tr' - k11t1 a Owner's Name Address 1510 LMS i+AZ IMO 64L � Phone Z M' t� 0360(a Contractor yZtt.-tta['t'1� .y ��' Hodress 2�'�� i°` r`�`'�rZnb Sl License No.�s� Z Phone �1 511.14V TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 7-�+=`--_L�2 FOUNDATION AGRICULTURE WELL OTHER WELL 17p- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 40 eavl C1 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation [I Domestic/Private O Gravel Pack O Tracy Type of Casing_ t > ("1 Public Cl Other n Delta Depth of Grout Seal Tempe-oRGcout t""t L LJ- I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. - tges Well Destruction O Well Diameter Sealing Material & Depth AXADtTi0►Jo� Depth Filler Material & Depth "7ET;4,1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 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 ne LEACHING LINE ❑ No. & Length of lines Tot I t FILTER BED O Distance to nearest: Well Foundation ��Projere U2& Pl to �OAn /,Y,94 Ivil SEEPAGE PITS 11 Depth SizeR /c(s ` �'Q SUMPS LI Distance to nearest: Well Foundation T1kQ 0 l k7I L DISPOSAL PONDS ❑ DIVI 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: F=1= 93Ksb I N-kere3z- Date: Si)V �R FOR DEPARTMENT USE ONLY ci Application Accepted by [ Q Date J Area Pit or Grout Inspection by �" Date�� / Final Inspection by (ter 4�� DateN Z Additional Comments: Applicant - Return all copies to: Safi-Joaquin County Public Health Services Environmental Health Permit/Services cl3 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 D FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMIT'NO. INFO / / CASH EN 13.24(REV.I i n sr 7 "l �� EN 14.2e ( LL