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APPLICATION � } � (✓) - �T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI(• ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469 420 ' ; # P 0 BOX 388, STOCKTON,CA 45201-0 88 PERMIT EXPIRES 1 YEAR FROM DATE ISS11. °ly7a� (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 9-111[0.3 and Section 9-11-115.3 and the Rules and Regulations ��o`f San Joaquin County Public Health Services. Job Address �O7 JS GC I r `J r 1 J❑1 f City ryV Lot Size/Acreage FZ. {\C- Owneis Name 'r 50�te1 �l^LS ii-_TtLnS�,, Address X00 �-• �-� � �'� - Phone Zfl�t-H3S 'O�OI 33 'Z'h�. Tey CIN Contractor C.(NtcoG t Co. Address �C parte - /y 14 ILL Icense No. �� Phone_2_ 4'CY-1 Lb TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT fl 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 ry ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing- P C05fl' pecifications Q I'I Public 1-1 Other 11 Delta Depth of Grout Seal pe of Grout I I Imgatron _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Stale UV&k'I Well Destruction ❑ Well Diameter Sealing Material i Depth JG� , Depth _ Filler Material A Depth l\N TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIfl/ADDITION I I DESTRUCTI u wifem permitted it publ.c sower is EN available within 200 feat l Installation will"me: Residence_ Commercial x Other Number of living units: _ Number of bedrooms t Character of soil to a depth of 3 feet: -Water table depth g5 SEPTIC TANK �' Type/Mfg �'IT-- 0 i n Capacity / S L 0 �i)_Q/ No. Compartments Z PKG. TREATMENT PLT. ❑ 1 1 Method of Dispo.al !c ICA Distance to nearest: Well 240 Fot�ndetion 1 U Property Line ZCvO ( -ProPseA akar LEACHING LINE ❑ No. d Length of lines S- Q a 5 8a �) Totalrlength/size it 2.0 FILTER BED ❑ Distance to nearest: Well Z70 Foundation / 55 Property Line V SEEPAGE PITS 11 Depth Siva Number SUMPS LI Distance to nearest: Well Foundation Property Line v DISPOSAL PONDS ❑ 1� 1 hereby crinify 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 of licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not t employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 /1 tion laws of California." 14-22-619t I W. The applicant must call to NI required inspections. Complete drawing on reverse side. Signed x . � (f Lt.A IJ Title: Data: q4l k! FOR DEPARTMENT USE ONLY ApplicistT Accepted byftlaDate q w dg- 'TA Area 416 Date c -Pit-or Grant-Impaction by %eg� Final Inspeotion by Date Additional Comments: ficor./ r. aA&&rr�ea, ian Ate p /Ai_ 7 � Applicant Return all copies to: San Joaquin County iqhlic Health Lmims G'L, Envvonmental Health P.O. gServices J �N`• 5 h! n.loaquin, O.B x 36 ,Stockton,CA 52 1-0368 !l_�. ��•� 61��{ INF AMOUNT DUE AMOUNNTT-REMITTED Cx H �jj RECEIVED BY DATE PERMIT NO. EM LD 14 IREV.1/a 51 EM 14as OFC L ZX a