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Q_ APPLICATION 1' II } SAN JOAQUIN COUNTY PUBLIC HEAL .l SERVICES ENVIRONMENTAL HEALTH DIVISION: 445 N SAN JOAQUIN,PHONE 0 P O BOX 388,STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM (DATE"ISSUED (Complete in Triplicite) i) Ili f1 Application is hereby made to San Joaquin County for a permit to construct and/or install the work hereiIn 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 San1Joaquin County Public Health Services. Job Address 2-.00 NdI`-r11 e,^-'k City1—O,21i" Lot Size/Acreage 5'o--n 7-&CLZv�,� G,avAtf' mog v.Yo � t1ed-*vr lia✓l ire dress 7759 5 ;r e,r-+ Ula 5 0 . to Phone $2 67S E Owner's Name a io s Contractor i9n, n Address Licen'se No. Ph Lurm l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n! DESTRUCTION ❑ out of Service Well 0 I PUMP INSTALLATION G SYSTEM RE�AIR, ❑�' OTHER ❑ Monitoring Well L' I DISTANCE TO NEAREST: SEPTIC TANK A_L SEWER LINES DISPOSAL FLO.A_ PROP. LINE FOUNDATION AGRICULTURE WELL 290"OTHER WELL 4-11 r PITS/SUMPS //4 4 INTENDED_ USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I I fJ Domestic/Private XGravel Pack ❑ Tracy Type of Casing_ P U(" ? Specilications ' 4d I'I Public 1-1 Other f3 Delta Depth of Grout Seai r y/g Type of Grout f e + 1 IrriUauon �Q Approx. Depth 1 1 Eastern Surface Seat Installed by by C-E)f'1 ._ x1/yy'�pp r�t,�a f t n Repair00,rk Done L3 Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter Sealing Material i Depth `I� 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.l 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 ❑ Type/Mfg Capacity li No. Compartments PKG. TREATMENT PLT. Cl ! Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines .Total Iangth/size FILTER BED n Distance to nearest. Well Founaation Property Line Ij SEEPAGE PITS It Depth Size 1 Number +' SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �I I hereby certify that I have prepared this application and that the work will be done in actor ance with San Joaquin county ordinances, state laws, and rules and regulations o1 the San Joaquin County 11. 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 mucall for all wired Ina c ' ns. Complete drawing on reverse side. Signed X_ — Title: Fy-d,�e-4 M r,4Lc10 r Date: . 1' FOR DEPARTMENT USE ONLY I a' [(a --q0 I �� Application Accepted by (Date l Ila •j 0 __ Area 1 Pit or Grout I II' nspection by Date Final Inspection by Date Additional Comments: p ,'i`/Lt`?►LlT t.5S17l� J� Itccr�e hOIcLmIr'• Cprl1� f"L ��J I. M5 Fro, ro, w w _ Applicant - Return all copies to: San Joaquin County Public Health Services "1 i 4 Environmental Health Permit/Services . 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 FIEE INFO AMOUNT DUE AMOUNNNTT cREMITTED CASH RECEIVED By f 1j, (1)PERMIT'N0. M �� F IO - f� b� b a t • EM 13-24 IREV.r/w Sl - EH 14-2e