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• APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SEF ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209) 469-34 P 0 BOX 388, STOCKTON, CA 95201-038; Complete in Triplicate) ✓ICl� # —..:L10I o("f�,C # 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. W7 F'r.e,A ie \A/O.+ r,rr I Q_ r.•„S IDL Oo11 Lot Size/Acreage /aa g4e re Job Address — - " ' I •' - "'• CirCVf1- u!orks I20o W. Fla �r stoc y65^ S000 Owner's Name Ce)yr_ /, anted ReCel VeIAddress PM F f0J r kfu Phone 1 / 99 YYrts� cc ►E � /Q -f ContractorAypliea Science iE.glAee Alddress11T7 05 . SUIT? 110 IMV;SII/License No. Phone ( /S TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ golf In SOTHERX MonitoringWell❑ DISTANCE TO NEAREST: SEPTIC TANK� �10�0•�0 SEWER LINES ie -fit DISPOSAL FLD. 41�y PROP. LINE �l FOUNDATION �ZL_ AGRICULTURE WELL OTHER WELL L 500 PITS/SUMPS ft (CoylCif 1Q� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �•^ Cl Industrial ❑Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing CI Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications FI Public Ll Other n Delta Depth of Grout Seal Type of Grout - I I Irrigation _ Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dona _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth _ Filler Material a Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sawer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 fest: Water table depth SEPTIC TANK O Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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." Contractors 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 applics mu call or al red map* io mplete drawing on reverse side. ] -r p� l Signed X Title: _P Tl % 1 P. fir Date: D�NT USE ONLY y Application Accepted by Date _/- f/ Area Pit or Grout Inspection by Additional Comments: Applicant - Return all copies to: (0,7A EM1324 1AEV.. / x sr EH 1421 Date Final Inspection by San Joaquin County Public Health Services Environmental Health Permit/Services 445 N. San Joaquin, P.O. Box 388, Stockton, CA 95201-0388 Date FEE NFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO. `y /v