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9.&rvV_Q r ea*A yr 7bm APPLICATION RArvS4 l��CiTi ue+tarC_n,i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES AlTJNJ ° T6 Al, GAiur riZ ENVIRONMENTAL HEALTH DIVISION ;7b 445 N SAN JOAQUIN, PHONE (209)468-3420 rCA P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (�►+b� '3 t - �"� �' 1?C/f/ (Complete in Triplicate) Application is hereby madeJ is County for a permit to construct and/or install the work herein described. This application is made in coapliance with $aa Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _MIN n-1 '"dZZ — 1"�' City 5`_4CtC-T'0N Lot Size/Acreage Owner's Name 3� C�ti:S WWiZtSAddress 1 ¢S -r±-- �►6 ' ' � � _ �. � L .� Phone tb X31 366 Gtr+e� Cw tZ S yr T Gi '�K Contractor+r" �(LtL i-I�f+ ( 1W -.Address KNR,_�_ C i"i%r_>Jar_tA License No. �.J��`��b' Phone 10 (3}-qv TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .5e r-E DISPOSAL FLD.N/A PROP. LINE~Sepa-A- FOUNDATION AGRICULTURE WELL trn' OTHER WELL PITS/SUMPS JL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing I C.1 Domestic/Private ❑ Gravel Pack* 0 Tracy Type of Casing_ Specifications 1'1 Public El Other f-1 Delta Depth of Grout Seal fit'"+ Type of Grout 06L I i irrigation _Approx. Depth l I Eastern Surface Saul Installed by 61 t G E.R�.fv V ivA f"p Q Repair Work Done L3 Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material & Depth Q.AJC 0k;tV,7r- t;O Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I INo septic system permitted if public sewer 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 feet: Water table depth SEPTIC TANK . O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method oLDj at l_ R_E��YM Distance to nearest: Well Foundation Property Line AAo■ LEACHING LINE ❑ No. & Length of tines Total length/size 22. 2 1992 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SAN JOAQUIN COUNTY SEEPAGE PITS 1 i Depth Size Number P D1VISi0N SUMPS L1 Distance to nearest: Well Foundation Property Lrne DISPOSAL PONDS ❑ 1 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 ampioy 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mWcllr all r fired U' cli s. Complete drawing on reverse side. Signed X Title: t=r i �I N2 Date: 6 yZ FO DEP RTMENT USE ONLY g Application Accepted by Date �4 �i ? Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: MRED:::: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY ATE PERMIT'NO, ` INFO • EM 13.24JAEV.7ini� S Sa _ EM 14.26 ✓ J �'�'�