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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P BOX 388, STOCKTON,CA 95201-038$ r. PERMIT EXPIRES 1 YEAR FROM DATE ISSIIID (Compute 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 in'ade in compliance will San Joaquin County Development Title Section 9-11110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. - Job �, G` 1' F City &OCf� "'► 1 Lot Size/Acreage Job Address i Owner's Name �M ke GIak f Gla rh U/&Address F Phone�� 7074�, T L It 1803 w M LtJ .4a ; Z 7;Z.0 gi4o -X5,2-1�F Contractor It,(1 r 1]�ltV�'hon �TbC.�TZ�hJ j G4 ci5Z!E2 License No. �� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of service Ne11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X Monitoring Well ❑ SO t tr a oil PVCs DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 'i' Dia. of Weil Casing C.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications D f'l Public C1 Other 11 Delta Depth of Grout Seal Q Type of Grout i I I Irrigation Approx. Depth Eastern Surface Soul Installed by - Repair Work Done 0 Type of Pump H.P. State Work D no_ Well Destruction - ❑ Well Diameter sealing Materiel i AepthrY�/G�11/� Fyri1f'rl� Depth Filler Material i-Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I INo septic system permitted if public sewer is available within 200 IeeLl 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of tines Total length/size FILTER BED 0 Distance to nearest. Wei! Founaatlon Property Line SEEPAGE PITS It Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property.Line > DISPOSAL PONDS ❑ 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 w Nch this permit is issued, 1 shalt 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 empioy persons subject to workman's compensa- tion laws of California." The applican it wired in pections. Complete drawing on�reverse side. - Signed X Title: _{ Tr�+L�� Date: IDr FOR DEPARTMENT USE ONLY Application Accepted by Date - Pit or Grout Inspection by Da Find Inspection by Date Additional Comments: r`a,>fi,��.7r s n Cr_s>` 1 �� r/rru l i�� - rr�rc r..�,,.c��u�►> i � -- �c.U� 7— Applicant Applicant - Return all copies to: San Joaquin County Public Health Services Ct[�LrrY;c2 Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388r FEE �J e t� INFD AMOUNT OtJE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT ND. M_ l/lJ fm 11•26 fl If