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a` APPLICATION SA,, i ��T COUNTY PUBLIC HEALTH SERVICES _Q[S�LI 0 SVAN J Q Q IN, ,TAL PHONE (209)468-3420 iVL��IT ::�IRE�Sl STOCKTON,�DATE�IOSS�UED YEAR FROM 'C' (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. � b Address V I I`� ^ D� City L 00 Lot Size/Acreage Owner's Name MAw— /2Address '13 UJ00 Phone � ( �L� Contractor _ �/UAddress License No. Phone VY-PE OF WELL/PUMP: NEW W L 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTAL LAT ON SYSTEM REPAIR 0 OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S 'L'FLD.' PROP. LINE V r FOUNDATION RICULTURE WELL OTHER WELL =PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A A CONS GTION SPECIFICATIONS't fl Industrial C3 Open Bottom 0"Manteca Di ;.�of,Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing_ Specifications I'] Public El Other n Delta De bf Grout Seal Type of Grout t I Irrigation _.Approx. Depth I I Eastern ;,,Surface eal Installed by Repair Work Done U Type ype of Pump W.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Maternal°&:D Depth Filler Material & Depth OF SEPTIC WORK: NEW INSTALLATION f 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: --J— Number of bedrooms Character of soil to a depth of 3 feet: _ .�,�Q-t � LAC�a T�Water table depth SEPTIC TANK ❑ Type/Mfg s Capacity _ No. Compartments PKG. TREATMENT PLT. D . Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ® No. & Length of lines 0 f Total length/size FILTER BED CZ Distance to nearest: Well t Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well �]Q^ Foundation Property Line DISPOSAL PONDS © Su w A M„ X `4 X R r PP ereby 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." he applicant t call for a,{ equi ed i pect'0- - Complete drawing on reverse side. Signed X a!20- tet. Title: ybkl/y&�- Date: FOR DEPARTM �USE NLY Application Accepted by Kl , L ate �2 Area Pit or Grout Inspection by Date //��Final Inspection by O Date Additional Comments: 2t'.•. 4 .0 .,1�0 G Applicant - Return all copies to: ,- San Joaquin County Public Health Services S 4 r tlp �fig For ','tEnvironmental Health Permit/Services •a- 449 N San Joaquin, P O Box 2009, Stkn, CA 95201 `�t..•a l� pJ t as....,a �- M INFO AMOUNT DUE AMOtJNT REMITTED � CASH CK RECEIVED BY , DATE PERMIT'NO. . £H 13-241REV.iin Si ] aZ �► O Or p0 rf ` 3�© � I £H 14.25 N / a