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✓�``" APPLICATION J SAN.JOAQUIN COUNTY PUBLIC HEALTH SE VAC. # � ENVIRONMENTAL HEALTH DIVISIO 445 N SAN JOAQUIN,PHONE(209)469-3 P O BOX 388, STOCKTON,CA 95201-03 AC# PERMIT EXPIRES 1 YEAR FROM DAT Gja;t (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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I 1 (API 1�liee&A Srrog:: city '5-fOC6 Lot Size/Acreage C h � �Q B G�+l e - .�[�+3�c/T66� Phone Owner's NameS�i �•�� +' ►�t^'�" Address Contractor GW mer - Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Ne11 Gl PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE _- FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing Ci DomesticIPrivate Cl Gravel Pack C] Tracy Type of Casing_ Specifications Il Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation —Approx. Depth t I Eastern Surface Seal lnstatlled by Repair Work Dont 0 Type of Pump H.P. -- State Work Done Well Destruction 0 Wall Diameter Sealing Material i Depth Depth Filler Nate TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/AD-DIT N I I DESTRUCTION INo septic slam permit - public sewer is voila ;thin 2 M Installation rve: Residence_ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r a VI: SEPTIC TANK ❑ Type/Mfg acity-----=R O.Vor rlents PKG. TREATMENT PLT. G] ENVIR N �of Disposal I H Distance to nearest: Well Foundatio VL TH ERVICES LEACHING LINE Cl Na. 8 Lengt ;nes Total length/aiza FILTER BED ❑ Dist to nearest: Well Founnation Property Lina . t SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line Df AL PONDS 0 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I Certity 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 Callfo is." ZTh applicant all requi rns s, C plate drawing on reverse side. Signed X Title: _ 44:h7ef� _ Date: I 3 FOR DEPARTMENT USE ONLY R Application Accepted by73 1-3 1 [(:P*__... Date Area C.— 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 388,Stockton,CA 95241-038FEE INFO AMOUNT DUE AMOUN EMITTED CASH RECEIVED pA PERMIT'NO. Zzl N • CH 13.741REV.+iIts i EH llae �7