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c APPLICATION t5 UI OUNTY PUBLIC OAQ HEALTH SERVICES 4� X0.11 It TAL HEALTH DIVISION fi �1 yl SAN JOAQUIN, PHONE (209)46$-3420 1�. P 0 BOX 2009, STOCKTON, CA 95201 T . 9 X01 .133 pER�1IT E%PIRES 1 YEAR FROM DATE ISSUED � Sgy {Complete in Triplicate) b th and/or instals Application is hereby made to San Joaquin County for a permit to construct, e work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules an Regulations of San Joaquin County Public Health services. L of o �� c a 2 d a 3447]'I. Lot Size/Acreage . $ye)).c.n6on Rd City i Job Address - .j1: Address E11-i-r- fLrLe2 OJL hitme Phone Owner's Name t �� 2024 Ir Chry21e2 License No. 371_ 560 Phone 462-7676 Contractor C-eCL2'�L ��' ZRC Address NEW WELL ❑ WELL REPLACEMENIC� DESTRUCTION L-1 out of Service well ❑ TYPE OF WELL/PUMP: OTHER ❑ monitoring well ❑ II PUMP IINSTALLATIO" SYSTEM REPAIR L7 5(J r SEWER LINES �-�-- DISPOSAL FLD. PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS - IG FOUNDATION AGRICULTURE WELL OTHER WELL TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 n INTENDED USE II --�—`"T Dia. of Well Excavation Dia. of Well Casing '4 n Industrial ❑ Open Bottom ❑ Manteca Specificationsi�— _ I Type of Casing_ VC Camp-aL xA.Momestic/Privatei TGravel Pack C7 Tracy Depth of Grout Sea 100 ' Type of Grout—w-_ I'1 Public Cl0 h ll Delta C Q� 9�ack { l i , � i I Irrigation 1 Qat A ox. Depth I I Eastern Surface Seal installed by [rLh ¢ of Pump su9 H.P. 112 State Work Done _ Repair Work Done L7 Type 6 n Sealing material � Depth P Well Destruction ❑ Well Diameter --— Filler material 6 Depth Depth 8 6 r TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITIO11 N I I DESTRUCTION I I (Nailabietrwthin 200 feetystem .) iI public sewer is installation wilt sell e: Residence— Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK II [3Type/Mfg Capacity_ --- Method of Disposal .� PKG. TREATMENT' LT. ❑ Property Line Distance to nearest: Well Foundation d Total length/size LEACHING LINE q ❑ No. & Length of lines Property Line C1 Distance to nearest: 1 Well Foundation FILTER BED i Size Number SEEPAGE PITS li 11 Depth Property Line SUMPS Ll Distance to nearest:-- -Well_ Foundation_ — 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 tin the performance of the work for which this permit is issued, I shall not employ any person lin such manner as to became subject to workman's compens " Contractor's hiring or sub-contracting signature compensation laws of California. certifies the failowrn9: •'1 certify in t rformance of the work for which this permit is rued, l shall employ Persons suet to km n's cfompensa tion laws of Califaf la." [�Cl/ . ! s ns. Complete drawing The applicant fo r on reverse side. Tide: VP C.9rzrtk GJev, Inc Date: 1 u�y 92 Signed F DEPARTMENT USE ONLY 1I: Date Area Application Accepted by A0 '11' c(�Q . Final Inspection by Data Pit or Grout Inspection by Date Additional Cam Into: A licantll= return l c es to San Joaquin County Public Health Services I�E'jr!G JL i L— Environmental Health Permit/Services D G� ` 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. i i IN,� 8t7a F Z [a a . EH 1724 IREV.v h Sl a,/ { EH 14.26