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APPLICATION -- - - SR # . y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI Ey �] !t'�1 ENVIRONMENTAL HEALTH DIVISION /1�D # . - i d'f 445 N SAN JOAQUIN,PHONE(209)469-3420 ^ P 0 BOX 388, STOCKTON, CA 95201-0388 FAC PERMIT F I RES 1 YEAR FROM DATE I (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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 2 t City ALftiRO Lot Size/Acreage. l� Owner's Name 5�� SAr19, t.�aC S!L� S_ Address �S �`{Orl CAW- �5W.�J 7Pho' lz-ZA'518. I! z 7� Contractor "✓ ^ C47r �tlxl,�Ctew.fO. q.. l 4� Hddress License No._:5-Ak5-n,4 Phone IW-4O4L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION ❑ Cut of Service Well 0 ' , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial _. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ p in ' w f Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �~ S f f'1 Public Cl Other I € Irrigation i1 Delta Depth of Grout Seal Tye� ApproxDe '`�y�r _ . Depth I 1 Eastern Surface Seal Insiatied by J s+ Repair Work Done .L3 T I i ype of Pump N.P. State Work Done 4inriklup Ali + Well Destruction ❑ Well Diameter Sealing Material &,Depth .r, ��4�1�� Depth Filler Material 4 Depth � N TYPE OF SEPTIC WORK: NEW INSTALLATION r I REAAfR/ADDITIt] DESTRUCTION l I INo se tic s stem N - P Y permitted if public sewer is available within 200 test.) Installation will serve: Residence Commercial_ Other Number of living units: _ Number of bedrooms �� 1 atw� pNL.�� TDT#,t, dw `3 ►s Character of soil to a depth of 3 feet: t 6 - Water table depth l SEPTIC TANK _) 0 Type/Mfg —F- Twos C0 - Capacit DD v-�..? L� No. Compartments J PKG. TREATMENT PLT. ❑ f r Method of Disposal fi \ _ -Distance to nearest: Well 7 ._ Foundation �j r —+ e� Property tine r9 LEACHING LINE ❑ No. 8 Length of lines — 49 Total length/size I FILTER BED 13 Distance to nearest: Well Foundation ! � Property Line SEEPAGE PITS ,]� Depth Size 3 Number MPS LI Distance to nearest: Well _iZP Foundation' (aQ r Property Line ` ♦ - 1 DISPOSAL PONDS ❑ I a I hereby certify that I have prepared this application and that the work will be done in accordance with San J rules and regulations of the San Joaquin County oaquin county ordinances, state laws, and 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, tion laws of California." I shall employ persona subject to workman's compensa The applicant must call for ail required inspections. Complete drawing on reverse side, y it i Signed l Title Date: e _ + s FOR DEPARTMENT USE ONLY Application Acceptad yby 'Date Area Pit or Grout Inspection by Date Final inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ' Environmental Health Permit/Services rr Z-L� 445 N.San Joaquin,P.O.Baa 388,Stockton,CA 95201-0388 o FEE ' l INFO AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y H DATE PERMIT N0. m . ` D � f/ - I