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r APPLICATION 1�15 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES gnu ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Jab Address {m.�T � �NELCseF, FT' City Lot Size/Acreage Owner's Name L��,. V �l 2,9-, Address VM0 �N.� Com•• r r?rrone L — 1 Q Cgt ln� Contractor ress� �� 1�� ifl\14� cense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHERMonitoring Well 13DISTANCE TO NEAREST: SEPTIC TANK R- SEWER LINES JoeDISPOSAL r'LD.�_ PROP. LINI _S FOUNDATION AGRICULTURE WELL /V OTHER WELL PITS/SUMPS A-11A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom a Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications- I'1 Public f.l Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth WEastern Surface Seal Installed by � Repair Work Done O Type of Pump AY-1. H.P. tate Work Done /y/11_ _ Well Destruction O Well Diameter /y� Sealing Material L Depth/411/`7' Depth 14///1 Filler Material i Depth 427 147-_ TYPE OF SEPTIC WORK: NEW INSTALLATION ' 1 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: 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.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of Cees Total length/size FILTER BED O Distance to nearest Well Founaation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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 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 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 applican st c for equired insR!sLigm. Complete drawing on reverse side. Signed Title: � �� Date: FOR DEPARTMENT USE ONLY Application Accepted by �y� Date 02 ( ` Area ` Pit or Grout Ins �" yi'''r�!v —7L// f , c t —7 Inspection by Date /' Final Inspection by / %\—=—��t Data ! II v / Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Savironmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK J CASH RECEIVED BY DATE PERMIT* NO. . EH 134b tHtY.r i n sr EH 14-28•?E 1 TrT , [VJ