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} APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 3o 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 In 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 7296 S. Bo,zPa CityS.tkn Lot Size/Acreage f50 acae- Owner's Name Na l ie C, " P e.t e2Z Address 13 am e Phone 464-7017 Contractor CXa tk VeZZ Address 2024" f. Chao-tea License No. 371560 Phones TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENVMXX DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L] OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 50 r SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation I Z Dia. of Well Casing 6'y Pd)Domestic/Private xjU Gravel Pack ❑ Tracy Type of Casing.l VC Specifications r 0 9 6 f? i'1 Public 1:1 Other XFa_hPelra Depth of Grout Seal f1 D_�Q ' _ Type of Grouted n r . 1 I I Irrigation Approx. Depth I I Eastern Surface Sea! Installed by o hon c Repair Work DoneType of Pump H.P. St to Work Done Well Destruction Well Diameter rf Sealing Material b Depth n�C V'A Depth 370x. Filler Material A Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms r; Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity Mo: Compartments PKG. TREATMENT,PLT.❑ Mithod of Disposal Distance to nearest: Well Foundation Property iLine LEACHING LINE ® No. & Length of lines Total length/sizes 1) i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property.Line DISPOSAL PONDS ❑ I 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 I 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant St all f r all r pe, ns. plate drawing on reverse side. Signed A TitleVP C�oak lJ� t?C?. I a c Dace16 au P y 92 i MENT USE ONLY Application Accepted by Date A►ea Pit or Grout Inspection bbyam Dated Final Inspection by Date Additional Comments: 6 Applicant - Return all copies to: San Joaquin County Public Health Services /RSA Environmental Health Permit/ServicesQ�V 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO lAfr AMS�ODUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. • IRtN.riN31 WWP, C/s� c r0o f Z-�'9-5 EH i4m /♦ fI 6