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APPLICATION SAID JOAQUIN COUNTY PUBLIC HEALTH SE VIS ENVIRONMENTAL HEALTH DIVISIO �� 445 N SAN JOAQUIN,PHONE(209)469=34 P O BOX 388, STOCKTON,CA 95201=038 3 J QAC PRIMIT IRES YEAR FROM DA TE (Complete in Triplicate): i INV ff .�,....� Application is hereby made to San Joaquin County for a permit to construct and/or.install the work hertin described."Phis application is made in compliance with San Joaquin County Development Title Section 9-1110.3 and Section 9-i115.3 and the Rules and Regulations of San Joaquin County Public Health Services. ' € VJob Address f 6-eh/ ._^_ lot Size/Acreage Z ��mr n Owner's Name ; r' t� i_ .. Address Phaner/��J G /13 Q } C7a�1 �Canlra .;��j- E i;+rr/ri« Address �1� .//�r Gb G 9j' Z icenseNo..j �E.�CI Phone ctar TYPE OF WELL/PUMP; EW WELL S❑ I ;WELL REPLACEMENT 171 DESTRUCTION ❑-Out of Service well: 0 PUMP INSTALLATION;G I . SYSTEM REPAIR 0 r =' i OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWERFLINES it .DISPOSAL FLD. PROP. LINE s 1 ' FOUNDATION AGRICULTURE WELL ' ? OTHER WELL PITS/SUMPS i INTENDED USE I TYPE OF WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS � Q 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Encevailon, Dia: of Well Casing Ci Dome stielPrivate' ❑ Gravel'Pack s ❑ Tracy Type of Casing_ # Specilications 1'1 Public g i .1 Others f fl Delta } ri Depth of Grout Seal i typepi Groui I I Irrigation Approx. 6epih I I Eastern' c Surface Soul Inslslleif by gepoir Woik Done .L? ;Type of Pump{ = H.P. t 3 State Work Done_ li Well Destruction O >Well Diemeteij Sealing Material:i Depth r Depth ( Filler Material i Depth ; I TYPE OF SEPTIC WORK:: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION N INo septic system permitted if public sower is I available within 200 feet.) s t ^ Installation will serve: ResidenceCommercial Other Number of living units: Number of bedrooms 1 i Character' of soil to a depth of 3 foot.) WNai /able depth SEPTIC TANK i ❑ Type/M1195� Capacity i F No. Compartments i PKG. TREATMENT PLT, Cl s r Distance to nearest: Well Foundation I raped"' "Y1W�1 �1 e LEACHING LINE 0 No. brlength of.linea iTotai 1Rae r FILTER BED ❑ Distance t' nearest: Well y Foundation _ � gtpppRyt`NraLiNlyf ! JV V Al TW FRR s SEEPAGE PITS' I I Daprh }'' Sirs I �R� HEALTH UIVI .- i f ulm SUMPS I I Distance to nearest: Well Foundation Property Line E DISPOSAL PONDS ❑ i I 3 ! i II I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Couniy ordinances, state laws, and s rules and regulations of the Sari Joaquin'county , o Home owner or licensed agent'i signature certifies the following: "I certify thai in the performance of the work for which this permit is issued, I shall not' 3 employ any person in such manner si to become subject to wdrkman's compensation laws of California."Contractor's hiring or subcontracting signature" certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject io workman's compenae tion laws of California." !. t. ! i „l a . . The applicant must call for ali required inspections. 'Complete drawing an reverse side. ; Signed '1✓yre,.��' �`. Title: /a r cr �/ � 1 . t Date: - y _� , 1 r FOR DEPARTMENT USE ONLY Application Accepted by Datet � f Area Pit or Grout Inspection by i ^pais ? Final Inapec:66n by Date 71(,Fl9,y Additional Comments: s lir! S s ' �L r�r� S oi� d; ,•5 �ru/teh iK Applicant - Rel:O"n aii copies to: Sin Joaquin Couniy Public Health Services SCO 71 dZ,,f t.....ep'coc+ec�rJ i. Environmental Health Permit/Services ; t w Q15 N.San Joaquin,P.O. 388,Stockton;CA 95201-0388';. "' `�°` ''7/ lk/Q y 1 c rHP ,r,, l t r FEE AMOUNT Dt1Lr .4 AMOUN REMITTED K Y AECEIVED'BY p E PERMIT NO. f f' INFO , EH t3.2t IRaV.iiRs� d EH 1M2a J, - meg