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APPLICATION .,r/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES *.0<3%0 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE(209)4693426 -51,13 - -71120 P O BOX 388, STOCKTON, CA 95201-0388 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Minor Subd. Job Address 21982 E. Mi ltM Rtyiri Cnvf.]nrien Lot Size/Acreage3-2Ar•_ TM•c Owner's Noma Rrvan h._ Rri ak Address 21982 E Milt-nn Rrt i Phone Contractor Ckm r/rdtti lflnr Address 219A2 h. Mi 1t-m RSA License No. Phone — TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ('I Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Inpauon _Approx. Depth I I Eastern Surface Seal Installed by Repan Work Done U Type of Pump H.P, State Work Done _ Wall Destruction ❑ Well Diameter Sealing Material i Depth Depth _ tiller Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sawer is (Soil Suitability Studyflor Septic SyStans Desicgl) available within 200 fast.) Installation will serve: Residence_ Commercial _ Other PhRK TEST CAILY AT THIS TDLZ 3 Number of living units: _ Number of bedrooms MS — 94—� Character of wit to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLL ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size 6,s ty FILTER BED ❑ Distance to nearest: Well Foundation Property Line '-4 Alif' a tng4 SEEPAGE PITS 11 Depth Size Number NJTY SUMPS LI Distance to nearest: Well Foundation Property Li1tw! I,',cRv10ES DISPOSAL PONDS ❑ PV rLI' m • 1, A-, 0��ISION I hereby certify that I hove prepared this application and that the work will be done in accordance with Sa J agwn county ordinances, sura 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 wNch this Perms is issued, I Mall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting 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. tion laws of California." The applicant�mysstt call for all required inspections. Complete drawing on reverse side. /-- Signsd ^'�^ Title: /�tyu7r-mow Ce+s•• r Date: ,Q�/ ; 19'& FOR DEPARTMENT USE ONLY Application Accepted by Date �Z4�q Area ZI) PR or Grout Inspection by Date Final Inspection by Data 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 4_7, INFO FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. . err ta.z.IRzv.11.sl -2 3 y, � 3 L 5 rrt A N y� a.....