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APPLICATION z JOAQUIN COUNTY PUBLIC HEALTH UVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE(209)469-3420 P 0 BOX 388,STOCKTON,CA 95201-0388 PERMIT E%PIRES 1 YEAR FRO!! 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 Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. i Job Address �. ✓I�LV�' Cal-sii CEJ Lot Size/Acre 'se Owner's Name (-:7 CJ L� YCirUf�1 C� PC �I�cG� P/ Phone �-' Contractor N'l1.Clfl2U LIUI-� GIJU•. Address PC- FPIX ZZ-3 L at E4q License No. Phong�t/-)Y! Z c TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIIO� 0 SYSTEM REPAIR ❑ OTHERry nitoring We ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IkP�� DISPOSAL FLO.�,, _ lPROP. LINE e" FOUNDATION O / AGRICULTURE WELL �/ OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing- T_ Specifications 11 Public 1-1 Other f1 Delta Depth of Grout Seal 69^3O Type of of Grout) I I Irrigation _Approx. Depth )✓LEastem Surface Soul Installedby��r�^'or�7 Repair Work Done ❑ Type of Pump H.P. $tats Work Done _ (` Well Destruction ❑ Well Diameter Sealing Material a Depth 2� Depth _ Piller Material a Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I II DESTRUCTION I I INo septic system permitted it public sewer is rl 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lim ria LEACHING LINE ❑ No. b Length of linea. Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lim i i SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lim DISPOSAL PONDS ❑ I I 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 prtfies the following: "I certify that in the partcrmance 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 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, t call for I required in ? /p1 (Sections. Complete drawing on reverse side. Signed x_J�E /ha✓tl� Title: l �i'/r`/J"�L� Date: l/D / i FOR DEPARTMENT USE ONLY Application Accepted by Date " T L - Aroa � —�¢, Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services . Environmental Health Permit/Services 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388FEE a INFO AMOUNTT DUE AMOUNT REMITTED CA RECEIVED By �j, DATE9 PERMIT NO. - EH tJ.2E(REV.11.11 - /7�1/� /`�� 6 11 ✓ n• FH te•m O�/b 7