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' - - - APPLICATION - ,law SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RfVIRONM[ENTAL HEAT•TH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009 , STOCKTON, CA 95201 AW -3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUF;D (1/Lw-1{� (Complete in Triplicar.e) Application is hereby made to Sam Joaquin County for a pe.it to construct and/or i=stall the work herein described. 'rh-. application Is made in c—Pllance vitt Sam Joaquin County Ordinance No. 549 and 1862 and the Rules amd Regulations of Sa` Joaquin County Public Health Se7res. Job Address C � ^' f;^� c+� �--z. b QT Ch:.l•�- D;,-I VL S"Rx�' : City � Lot Size/Acreage Owner's Name Nkcl �c�-5 �K -t Address�-+-C• �2�. l��A ��- Phone(E 5)S71-Z�(Ec ....-� .moi... O � G{ 4-•1 O L- Cantractor�u� �x��e•-a Address �st..4 .- ('- C( 7.( License No C Phone 'SZ-7•I S� TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT M DESTRUCTION O Out of Service Well L PUMP INSTALLATION O SYSTEM REPAIR Ll , _ ER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES J Wim DISPOSAL FLO.�� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS mr— X 1— 1 t-Ic r,4 O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing '7 (-1 Oonest,c/Private Gravel Pack' 0 Tracy Type of CasinyL g_P 5`.1' 4a Specifications 1.1 Public 2I.I Other Delta Depth of Grout Seal /,O'/Z' / Type of/�Grout' Cc. u^�%�->- I I Irrryfa(gn �'Approx. Depth I I Eastern Surface Soul Installed by fes"^r C-o if �-Jpo-a Repair Work Done U Type of Puma H.P. - State Work Done_ Wall Des"uctron O WON Diameter Scaling Material i Depth Depth Tiller Material i Depth TYPE OF EPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if Oubl,c sewer is available within 200 feet.) Installation will serve. "CO Commercial— Other Number of living units: bar 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.O Method of Disposal Distance to nearest: Well fou ion Property Line LEACHING LINE Ll No. 6 Length of lines To ngih/size FILTER BED O Distance to nearest: Well Foundation Pro Lina SEEPAGE PITS 1 I Depth Sue Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS O 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la rules and regulations of the San Joaquin County ws, an Horne owner or licensed agent's signature cart,fies the following: "I certify that in the performance of the work for which this permit is issued, I shall nc employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signstur certifies the following: -I certify that in the prrtt erfoance of the work for which this permit is issued.I shall employ parsons subject to workman's compg nsa tion laws of Califomia." �n The applicant must call for MI required inspect. a. Complete dra Q O ever ide. Signal XTitle: Dat.- l FOR DEPARTMENT USE ONLY Application Accepted by Oats Area Pit or Grout Inspection by Oats Final Inspection by Data 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 FEE AMOUNT OU AMOUNT REMITTED CK RECEIVED BY INFO CASH OAT E PERMIT NO. EM 14-y