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APPLICATION - - - I JfrR - SAN JOAQUIN COUNTY PUBLIC HEALTH # ICE p'p ENVIRONMENTAL HEALTH DIVISI�1��€ ' k�e — 445 N SAN JOAQUIN,PHONE(209)469-3420 <v P O BOX 388, STOCKTON,CA 95201-0388 -- _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M§-a4-6(Complete in Triplicate)- 94 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 9rr-„1115.3 and the Rules and RegullIati�`onss.of San Joaquin County Public Health Services. Job Address A831 2310 ky gZ�430( 1\r 12F VFlES Cny !-'0VI Lot Size//'Acreage 14-9 -t Ac Owner's Name qL JJNl41 io `� I` --6 Address 21�� .�1 Y�.� � I1JoI Vi V 73.4-1 �`� n A �/2 ��1 ��r-� p Phone L. p Contractor �aIANBAGH f I/ ft Address 3 L J W EW f Tr Lw Licceen o. 16! Phone 3 LC (20 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRU TION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O ER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL TS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'1 Public I1 Other fl Delta Depth of Grout Seal Type of Grout I I Inigauon _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. __ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth E Depth_ Filler Material A Depth TYPE OF SEPTIC WORK. NEW INSTA - D 7fIFfYADf t DESTRUCTION I I (No septic system permitted if public sewer is GtZ( Gu117tc1,� ��'al I :JaL-U available within 2001aet.) Installation will serve: Residence Comm-erciat_-9ther M� ��Y � f-aT��a 1a1 _ �� irr Number of living units: _ Number of bedrooms V1 1l�'o `ADF�t &! Character of soil to a depth of 3 feet: Water able Eda4pth �+ U ( SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Proper , FJtIG O Distance to nearest: Well Foundation Property Lina � �(. l \ LEACHING LINE Cl No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well ion Property Lina DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and thH4yw r ne in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County f 7M! 94$941 Home owner or licensed agent's signature certifies tjI IA '11�aitif�lT3fhn the per ormance of the work for which this permit is issued, I shall not l\ employ any person in such manner as to become {q<oc ®�gr�I�1ALT ,nA ;on laws of California.” Contractors hiring or subcontracting signature certifies eM following: "I certify Ihe[in the parlor Q rorp 44ddr1drlj E'h4 rmit is issued. I shall employ persons subject to workman's compensa- tion laws Of California," H VV��pp�� n The applicant must call for all required inspections. Complete drawing on re erMa. f w+ Signed X Title: Date: j 'FOR DEPARTMENT USE ONLY Application Accepted by �� Le�--G-4st..e---�- Date Area ` Pit or Grout Inspection by Data Final Inspection by 'PUllDate 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 <^ INF E AMOUNT/DUE AMOUNT�n/R�EMITTED CSH RECEIVED BY DATE PERMIT NO. • EX 1]N IaEV.Irnpl P \ t toj n.. � !II1A. c;� 151 P,