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SR # �, APPLICATION 3 5 fft� O � AID � � SAN JOA IN COUNTY PUBLIC HEALTH SERVICES I RONMENTAL HEALTH DIVISION•� ZQ 3�75-01 .CaU� Fx 445 N AN JOAQUIN, PHONE (209)468-3420 —fk[g+ „lCj# BO% 2009, STOCKTON, CA 95201 IN # EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) FILE C i 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 1662 and the Rules sad Regulations of San Joaquin County Public Health Services. Jqb Address 3L431`t 51 BLQl"7_ SE zC_1rL , a City _ Lot Size/Acreage 'l rrJ Owner's Name Address '72N1c Phona 11to Contractor Address Y.BZS 16 t YKk19TLa. ST.-GAUt icense No. 15l'L'LLA? Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i1 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)< Monitoring /fWell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 71TOI- tNVE FOUNDATION AGRICULTURE WELL OTHER WELL —h4R& �� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Wtt` �'C `� — tC�2 D Industrial 11Wel Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of V511111 1] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications r Il Public C1 Other n Delta Depth of Grout Seal Type of Grout i I Irritation Approx. Depth I I Eastern Surface SBAI Installed by Repair Work Done L3 Type of Pump H,P. ____ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIRIADOt710N I I DESTRUCTION I I [No septic system permitted it public sewer is ( � available within 200 feet.) V� 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, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED F) Distance to nearest: Well Foundation Propeny Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl 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 Jaws, and rules and regulations of the Sart 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 subcontracting signature i 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 Title: W ' Date: _ U`_TL3 411 OR DEPARTMENT USE ONLY n �{ Application Accepted by 1-610 Date Area Pit or Grout Inspection by pate Final Inspection by Date ! Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services !]i Environmental Health Permit/Services ` 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE tEr INF/O1 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH 13-20IREV.vn57/IYXL,/ �/j'�''j�'• T47