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a (= APPLI GATT ON FOR PTRId I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERM T EXPIRES 1 XM 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. I Job Address � lQ f, ' jKC° City D Lot Sint/Acreage /24CG_ -/79 .3 vrner's Name r f t� �E &1=6 tea) Address jam' Phone _,.,. .CQntta[toc .: L -.- .':_ - 171 —Address V--16 � �c L-icense-Na. Phone TYPE OF WELL/PUMP: NEW WELL.Z WELL REPLACEMENT DESTRUCTION XOut of Service Well Gl 1 PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C3 OISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD., PROP. LINES t 0. FOUNDATION AGRICULTURE WELL J OTHER WELL% - PITS/SUMPS Aq9 , INTENDED USEF TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-2 L):Industrial i� 'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Darneatic/Private G! Gravel Pack ❑ Tracy Type of Casingt°��=F - Specifications 11 Public i� 1-1 Other 1. Fl Delta ,`, 'Depth of Grout Seal Type a rout I I�Irrigation Approx. Depth I Eastern J uriaca Seal Installed by ,4 1X11 1t-��L 1!� ,.. Repair Wo►k Done ❑ Type o1 Pump H.P. tat W k Dan f Will Destruction Well Diameter Sealing Material i Depth Depth Filler Material i Depth , T PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l 11No septic system permitted if public sewer is :Ileavailable within 200 feel.) �nslallation.wiil-sekre :-Residence--.-Commercial's- .-Other-----,.- --,wY�•- �. R --.-�-•-- dumber of living units: Number of bedrooms Character of soft to a depth of 3 feet: Water table depth SEPTIC TANK: O,Type/Mfg.-~ -- Capacity No. Compartments P G. TREATMENT PLT. C1r r Method of Disposal .-Distance to!!!nearest: Well-- Foundation Property Line 4,� CHING LINE ❑ 'No. b L gth of linea Total length/size F rsr FILTER BED 0 fDistance,to nearest. Well Foundation Property Line t I SEEPAGE PITS1 1 Depth Size Number I K SUMPS _CI_,Distancs to nearest: Well Foundation Property Line I DISPOSAL PONDS ; ❑ / t I hereby certify that�l 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 I i Home owner or licensed agent's..iignature 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•tiontracting signature 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 ill.required;ictions. Complete drawing on reverse side Sig Till e:--^�-C-aG1A Da[e: 1 FOR DEPARTMENT USE ONLY I Application Accepted by Date ��lL. Area Ph,or Grout Inspection by ate z Final Inspection h, Data _6L - ' J � J Additional Cammanli: C> >d� � � J`� � Applicant -s�Return al co pi to: San Joaquin County Public Health Services , Environmental Health Permit/Services 445 N San Joaquin, P O`Hox 2009, Stkn,,0A,95201 EE ` INFOII AMOUNT DUE AMOUNT REMITTED K H ?RECEIVED BY DATE PERMIT'NO. . + EN 13-24 EN L7 of ism+11EV.iifltil w� 1 �,�© c r0� Q ;� IN