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. v APPLICATION FOR PBRHI%4 # 00Z vo SAN JOAQUIN COUNTY PUBLIC HEALTH SEM ENVIRONMENTAL HEALTH DIVISION D_# 445 N SAN JOAQUIN, PHONE (209)468- P 209)4#38 P 0 BOX 2009, STOCKTON, CA 952 lFAC# 71(Complete in Triplicate) I .,XMIL Application is hereby made to Baa Joaquin County for a permit to construct and/or install the vork 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 Z10t__L S �+ u"/ v�'�"�' CityllL`'r�6& Lot Size/Acreage eC--'e Xax foJ2 Owner's Name k'r" Address Coo c+^A CA f f Z f- Zo32 Phone _ � ;Z41 �r•A/i1��...�(.( alp, i-Ar Z / ContraciaLL".., •�•7i•wr lAt. Address /Pt.4 (.�r.Pe,n G'fro2 License No. l oZiL7.0 Phont/ gS2" TYPE OF WELL/PUMP: NEW WELL;. WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well ja DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES > DISPOSAL FLO. S-4" PROP. LINE "126 FOUNDATION , a,� r_ AGRICULTURE WELL OTHER WELL 7 rpl UMPS >P INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial O Open Bottom O Manteca Dia. of Well Excavation s. of Well Casing Z" Cl Domestic/Private O Gravel Pack O Tracy Type of Casing__ 10yC Specifications S`4 dfo i'1 Public 0-01her fl Delta Depth of Grout Seal S Type of GroutNa•f Cu"C-41( * �►uafsR �t I I Irrg �ration Apgox. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O WON Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_. CommercW_ Other Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capecity No. Compartments PKG. TREATMENT PLT.O motlhod of �. Distance to nearest: Well Foundation Property Line resiv LEACHING LINE O No. 3 Length of lines Total length/sirs FILTER BED 0 Distance to nearest: Wel Foundation Property Line � SEEPAGE PITS I 1 Depth Size Number 4�IGAI�T{-I Number �[•REA1 Its SUMPS Cl Distance to nearest: Wel Foundation Property Line DISPOSAL PONDS O 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 which this permit is issued, 1 shat not employ ow person in such nwtttat as to become subiect 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 e s cortipama. tion Iews of Califomis." The applicanr-cz-,x all for all required ineWtions. Complete drawing on/reverse side. / Signed X l_ •...�(cr Title: IT'7 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date F ction b" +' ZDate Additional Comments: Z Applicant - Return all copies to: San Joaquin County Publ tc Health Ser ces -02, Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009,_Stka, CA .95201 FEE INFO AMOtJN7�Ot1JE AMOUNT REMITTED CASH RECEIVED MY DATE PERM11'NG. . EN 14-21 111Ev.�,w 6► ]C x I // EN 1411 V LJ [ [�` /