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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 ti SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388,STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Seion 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address [230 s c,JJ AUG City It-0,0 Lot Size/Acreage /0+ Owner's Name Lob i kc,,+I f t'7 Address S4Mt-Z- Phone 3L Contractor ` U.I66I Address 130*sl 810 Yu%Pr '14511 License No. 651?74F4 Phone7/6'P31`71&Y TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK AW6 SEWER LINES /OBS + DISPOSAL FLD. PROP. LINE 4G0 FOUNDATION _-l[L_ AGRICULTURE WELL NOR OTHER WELL_A ]& PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 0 Industrial 0 Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing C.1 Domestic/Private 0 Gravel Pack C Tracy Type of Casing_ ItQ2ViF Specifications VIA- (11 ffi('1 Public (-1 Other f' Delta Depth of Grout Seal Q-XV'ToAl Type of Grout ffi'?SC.kN� I I Irrigation gtv-Approx. Depth Eastern Surface Seal Installed by ?11A Repair Work Done U Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ' I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 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 suboct to workman's compensation laws of California." Contractor's hiring or subcontracting 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 My&t cyaliffo�r all r red inspections. Complete drawing on reverse s1 e. Signed X f/1'I Title: ?�YAC4 is /TtaieJ 1 �' Date: f/8/� / FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: Sm Joaquin County Public Health Services Fzvironmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 IFEENFO AMOUNT DUE AMOUNT REMITTED /CASH RECEIVED BY DATE /PERMIT-NO. M EH 11REV.fin EH 142a 4.26