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APPLICATION SR # 3S SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI 7R1D # ENVIRONMENTAL HEALTH DIVISION li Lb 445 N SAN JOAQUIN, PHONE(209)469-3420 �4C # P O BOX 388, STOCKTON,CA 95201-0388 I O� PERMIT E%PIRES 1 YEAR FROM DATE ISUID �' — V1A/ (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�S�an Joaquin County Public Health Services. Q ,f /(,�lt ! ///_•rS✓ ROAD C.Iv LGvg"19(}�Lot Site/Acreage 37 Are, •� f'SL Job Address FJ J �1p7�G�/� Owner's Name 0A1B� VAP! DTI& Address 3.5'07 !s4LLV RSD ST!^-D 111j - Phone Contractor E 1- 14 P• Address 1�'�s N"€y'f7E'PACG'1 License No. Phone -L O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I-1 DESTRUCTION ❑gut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER V Monitoring Well ❑ prat, MVr 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 Ll Industrial ❑ Open Bottom ❑ Manteca Die. of Wall Excavation Dia. of Well Casing .� N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'I Public I I Other fl Delta Depth of Grout Seal Type of Grout f w 1 1 Imoauon _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump N.P. -- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permrlla�jllgyplicseywar is available within Z 3/G EJ Installation will serve: Residence_ Commercial _ Other JUN A 4 1994 Number of living units: _ Number of bedrooms r�ARUIN COUNTY Character of soil to a depth of 3 test: Water loTT& ><ty SEPTIC TANK ❑ Typo/Mfg Capacity No. CoNT 1$ION PKG. TREATMENT PLT. ❑ Metlt tl1'Blspoaal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. B Length of lines Total length/size FILTER BED Cf Distance To nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 workmen's componss. tion laws of California." The applicant m all for all inspections. Complete drawing on/rA/versa side. / q� Signed X Title: P.GI%h.L•- Data: (s '�T- ,L7- FOR DEPARTMENT USE ONLY Application Accepted by Cah Do i v �Aii Date 6� Pit or Grout Inspection by / Date Find Inspections Dain�� Additional Comments: >�1464 — Applicant - Return all copies to: Sen Joaquin County Public Health Services Environmental Health Permil/Services l I� 445 N.Sen Joaquin,P.O.Box 388,Stockton,CA 95201-0388 INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE �PERMIT'NO. `.`EH132IIIN•tr