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APPLICATION ++ 7,5� _6 `' SAN JOAQUIN COUNTY PUBLIC HE TH�gE '4"= _ ENVIRONMENTAL HEALTH DI I rD -tiff' ' 445 N SAN JOAQUIN, PHONE (2 9 d?n. _ P 0 BOX 2009, STOCKTON, FA if PERMIT EXPIRES 1 YEAR FROM EATE..ISSUED V A t (Complete in Triplic t /"' I S "6 G D 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. �.+ Job Address "4! XpA ST Acreage City S?"XAJ Lot Size ,�./15 Owner's Named M&AZZVES Address l AA64, AA II CAC 1G 1 Ak7 Phone Contractor F1 0.Dra. WA&D Address !7 AA ACEI <rY-? "IcLicense No. L_C].7L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS p INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f.l Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications I'l Public 11 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by (� Repair Work Done U Type of Pump H.P. _ State Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 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: 1— Number of bedrooms Character of soil to a depth of 3 feet: (° `Q' Water table depth I" SEPTIC TANK D Type/Mfg A:— �(LST'/All, Capacity No. Compartments 1� PKG. TREATMENT PLT. Q Method of Disposal �} Distance to nearest: Well Foundation Property Line / I LEACHING LINE U No. & Length of lines Z " 4Q If Total length/size FILTER BED ODistance to nearest: Well W .1Foundation 3e) " Property Line 7--t900 �- SEEPAGE PITS ICi'/Depth 2C 1 Size 31-16 b. Number 2— SUMPS SUMPS LI Distance to nearest: Well �Qt' �Foundation 7AQ 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 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." The applicant must call for all required insPections. Complete drawing on reverse side. Signed X � �0' V� Title: Date: -Z7-g3 FOR DEPARTMENT USE ONLY �`^ Application Accepted by \o ��Y��---c' Date Area Pit or Grout Inspection by Date Final Inspection by Data �f Additional Comments: v J-A /054/4w `tip•- U vV Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services JA,JI 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO ` J�CASH . EM 13•Y4(REV.riNsr / r / EH 14.10 V _