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APPLICATION l"Is SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �ja z Job Address �� (iri lose- " y�' City ��h�ee� Lot Size/Acreage ! gCre Owner's Name/`aux 1-,,) Pok l eS Address 7o;? �A�re"� Phone -`115 _ jJ f 3GG3 o�te� Crl"c�C°� s �JiB o1 p Contractor v{i r�! ,p Address Ar+Ncko Co l/1 (h 7-57Y?- License No. /�za Phone�� G 31�9;3i� TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS /OO' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom Manteca Dia. of Well Excavation -r I+c Dia. of Well Casin 2-fhg XDomesticl Private XGravel Pack ❑ Tracy Type of Casing- Pyc Specifications aka I'I Public 1-1 Other f-1 Delta Depth of Grout Seal K rQPe Type of Grout I I Irfigation 3-0 Approx. Depth I I Eastern Surface Seifi Installed by Of ord" Repair Work Done L3 Type of Pump "'^ H.P. State Work Done_ Well Destruction O Well Diameter 2-1we-� Sealing Material J Depth Depth _30=fN& Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/A OITION I i DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feel.) 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 ❑ Type/Mfg \F,. ,ticn ap city No. Compartments PKG. TREATMENT PLT. C1 Method of Disposal Distance to nearest. Well Property Line O LEACHING LINE ❑ No. & Length of lines N Total length/size FILTER BED ❑ Distance to nearest: Well Fo iclation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foun tin Property Line DISPOSAL. PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be don 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 t is 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 compensati in 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 p Emit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must cal ff all uired inspections. Complete drawing on reverse side. Signed X ag" A x Title: f)411 S Date: -7/�I3A FOR DEPARTMENT USE ONLY i!�i Z4::(00 Application Accepted by Data ` Area Pit or Grout Inspection 1date l r Finai Inspection by �q Additional Comments; Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Per it/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASHK 9 Page 13f RECEIVED BY DATE PERMIT'NO. • EM 17.2 fREV.vMSi INFO f M 11-2a