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SR# (� SAN JC IN COUNTY PUBLIC HEALTH Srt `I CES f! IRONMENTAL HEALTH DIVISION...! AID# --- 445 N O%JOA UIN, PHONE (209)468-3420_,^, ,.,, .- .; r I r STOCKTON, CA 95201 _ L I =�.-r,4 FAC# E%PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �� INV# Application s unty for a permit to construct and/or !:stall 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 Countyy Public Health services. CL Job Address , L `G��'e� y�- City ': +Z � Lot Size/Acreage _ j. Owner's Name rev kDLLV%A VKeS Address Sof/ 11;,1!J7. Phone(214J) -6671 C D�s►u,A s, 7X Contractor JQ�C�� fC�yy\ �CQL,�ddress 2925 /1�ajr7�( 5 License No. `7GS" 8712 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION C1 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER )< Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK �— SEWER LINES L 50� DISPOS:.L FLD._WA PROP. LINE 2 / FOUNDATION (e� AGRICULTURE WELL � OTHER WELL_ZV_14 PITS/SUMPS :TE'::.`G USc TYPEE .,F PROBLEM RftEA, CONSTRUCTION S?:CfF!Cr750.`dS C' 5,1.� �?.7d'L:J � U•� Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of basslP Excavation Dia. of Well Casing 71 Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications 1'1 Public Cl Other fl Delta Depth of Grout Seal q$ .LIE Type of Grou I I Irrigation —Approx. Depth I I Eastern Surface Soul Installed by So 121101-4-L"0%1) 6 L. . Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth 53 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is [n available within 200 feet.) V Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE C) No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Una DISPOSAL PONOS O I hereby certify that 1 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, t shall not employ any person in such manner as to become subject to workman's compensation laws of Cstiforria." Contractor's hiring or sub-contracting signature certifies the following:"1 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 spot, nt m at call for all r ireo i pections. Complete drawing on)OU" side. U, Signed title: /�fLt�"a r s,✓ Date: ALF R DEPARTMENT USE ONLY xry Application Accepted by Date v Area Pit or Grout Inspection by R ate Final Inspection by Date Additional Comments: ��` 'S 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 D/ FEE INFO AMOUNT CDUE ��7f AMOUNT RE�MX�I�T.cT�./Ef�D CASH RECEIVED BY DAT`EE� PERMIT'NO. EM 1334 t11Ev.I/As)