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APPLICATION ..)R # SAN JOAQUIN COUNTY PUBLIC HEALTH SE ViC 4. ENVIRONMENTAL HEALTH DIVISION I ,I� 445 N SAN JOAQUIN,PHONE(209)469-340E-f l r, P O BOX 388,STOCKTON,CA 95201-038 v PERMIT EXPIRES 1 YEAR FROM DATE I ISSUE'! (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. Job Address S tl23,5s. L,2 , City 0. Cat Lot Size/Acreage Owner's Name G11M Slc`1n'e- Address S`{&O E u-p-IN 1n Phone 50AY7-,!q( Pay �] i is eY W1 t3If le C. [�I Contractor ayV% Address v + �4150� wQ License No, Phone - 07 �. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT In DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 [' D Industrial ❑ Open Bottom © Manteca Dia. of Well Ji Excavation Cl Domestic/Private C1Gravel Pack C3 Tracy Type of Casing f"1 Public L1 Other fl Delta Depth of Grout Seal I I Irritation _Approx, Depth I I Eastern Surface Set,l Installed byrf ." 2 1994 Repair Work Done ❑ Type of Pump H.P. State Work Done vel Well Destruction ❑ Well Diameter Sealing Materis.1 i Depth SAN JOAQUIN CQUIVY Ll Depth_ Filler Materiel fi Depth PIJBLIC H EALI H bERV ICES I I DIVISION TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION DESTRUCTION I I IN 7iepfic system permitted if public sewer es { /y f available within 200 feet.) I Installation will serve: Residence— Commercial_ Other "e Number of living units: 71 Number of bedrooms f Character of soft to a depth of 3 feet: _ ..f1. F___ _. 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. 5 Length of lines __W 0_ v- q 0 Total length/size If FILTER BED 0 Distance to nearest: Well Foundation Property Line = SEEPAGE PITS I I Depth Size Number SUMPS L1 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 which this permit is issued, I shat!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,1 shall employ persons subject to workman's compen&a tion laws of Calilofnis" The applicant i st Il for all require rn peetions. Complete drawing on reverse ide� ISigneTitle: Date:. ' FOR DEPARTMENT USE ONLY t� � Application Accepted by � � Date � � T Area Z" i 4 1 Pit or Grout Inspection by Date Final Inspection by i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 a F EE AMOUNT DUE AMOUNT AEt.11TTfD RtUIV M r INfO SH ED 8Y DATE PERMIT'NO. �., EL EH tae