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a APPLICATION � Namt� 7�0 • !zA New 6 is{'�"Cf%.�-i•t tit+t;A i_ ( � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES AiTP%j " ZM f3aL13r'`iZZ ENVIRONMENTAL HEALTH DIVISION -7 1 N DQS�:M-1 AL,f>t.✓J: 445 N SAN JOAQUIN, PHONE {209}468-3420 , cam P 0 BOX 2009, STOCKTON, CA 95201 _ PERMIT EXP I RES 1 YEAR FROM DATE ISSUED 3.7 3 / 7/ �2r�� (Complete in Triplicate) Application tips hereby�madeJ in County for a permit to construct and/or install the work herein described. This application is made in compliance with San Soaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. -. i Z - 43 L"? - GL Job Address %-)-I — City Lot Size/Acreage y Owner's Name C�fiT� APRIL! IES � Address 'f0 r _ Phone q%6 3$r'- 36&.) X663 GM LatZ, f,tT1a" ContractoS+r y21k_k l & Address RIirNU+_,, Coss��,�r 4A License too. �Z Phone a6 631 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES :lar t''r, DISPOSAL FLO.11A PROP. LINE�� 'r FOUNDATION AGRICULTURE WELL t-l^" OTHER WELL PITS/SUMPS �r• INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS In Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public 1-1 Other n Delta Depth of Grout Seal 'fType of Grout 4a^-LJ_ y� I I Irrigation —Approx. Depth 11 Eastern Surface Seal Installed by t- L1 'TIS Gn` Repair Work Done Q Type of Pump H.P. State Work Done f;: 6q0.Nk)ivAT i2_ Well Destruction ❑ Well Diameter Sealing Material i Depth �1JC rti,PV'w 11 -L, Depth Filler Material 3 Depth 5 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIRIADDITION I I DESTRUCTION l I (No 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 depih SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method oLDjsQa��i_ Distance to nearest: Well Foundation Property Line MWM (fin ENT LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wall Foundation Property Line SAN JOAQUIN COUNTY SEEPAGE PITS 11 Depth Size Number P �UL-D N SUMPS LI Distance to nearest: Well Foundation Property Line 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 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 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c II for all r ired inspecti ns. Complete drawing on reverse side. Signed KTitle: f�i' 15ivli.,$V Ey-2 Date: �Z— FO DEP RTMENT USE ONLY � Application Accepted by Date W — Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 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 f> FEE INFO AMOUNT DUE AMOUNT REMITTED C SM RECEIVED 8Y �, ATE PERMIT NO. r . EN 13.24 tAty.bots) + 3aa2 �y 6 PUV fN t1.2e S