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APPLICATION 1, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209) 469-3420 P 0 BOX 388, STOCKTON, CA 95201-0388 .4 Ili:. - r t�PFMIT MIRES 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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. 1' a Job Address bow �� &I.Ay-A bh',,,e City S-b�[� Lot Size/Acreage �i Owner's Name h Address w „ Phone Z69 _C?y8 07.T L_• 11 '� r �� ,�y �j. � f� �� Contractor S'tT�Y+�►iv.oh Address �. License No. �` 2 -vg Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTIONXQut or service well L1, PUMP INSTALLATION 0 +' SYSTEM REPAIR 0 OTHER ❑ - Monitoring well:. DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca „ Dia- of Well Excavation Dia. of Well Casing fa Domestic/ Private 'El Gravel Pack ❑ Tracy 'type of Casing_ Specifications III Public (:1 Other i Cl Delta Depth of Grout Seal Type of Grout I i I I Irrigation _--_ Approx.LDepth I I Eastern K Surface Seal Installed by Repair Work Done 0 Type of Pump H. P. State Work Q,ppne _ f 1 ' i Depth L-A 11�1U1tit A'+�3 Well Destruction Wal( Diameters Sealing Material i Depth ! S ]Tiller Material i Depth Sem000mvp, TYPE OF SEPTIC WORK;' NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is :I ..I =� {• available within 200 feet.) j Installation 'll serve: Residence Commercial _ Other Number of livin its: Number of bedrooms 'Character of soil to a of 3 fest: sI Water table depth SEPTIC TANK C3TCapaci No. Compartments f . PKG. TREATMENT PLT. ❑p I4 Method o Deposal Distance to nearest: ell i Foundation Property Lir» � LEACHING LINE ❑ No. b Length�fi' Total length/size FILTER BED ❑ Distance t Well Faun Property Line L SEEPAGE PITS Depth -Size vi Num Foundation Props • "I SUMPS LI Distance to nearest: Well " DISPOSAL PONDS ❑ 1 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 employ any person in such manner as to become subject to workmen'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 @hall employ persona subject to workman's compensa- tion laws of California." The applie ust c II f I req 'red inspections Complete drawing on reverse side. Signed if Title: Ui� C�©IQ� Date: + �� I • _FQR DEPART NT USE ONLY r— _ � O • Application Accepted by ` Date Are@ J Pit or Grout Inspection by Date dd Final Inspection by Date Additional Comments: - I Appl icant - Return all copies to: - - San Joaquin County Public Health Services r Environmental Health Permit/Services� „ - 445 N, San Joaquin, P.O: Box 388, Stockton, CA 95201-0388 i FEE INFO AMOUNT DUE 'A AMOUNT REMITTED CASH RECEIVED BY D.AATE; P]ER�MIi'''NNOj. •t'1 EM 13•14111EV, f / h 500feorfn 1 a EH IC26