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APPLICATION SAN]OAQUIN COUNTY PUBLIC HEAL SIad11TFS/ b V S ENVIRONMENTAL HEALTH DTVI 10 IT 445 N SAN JOAQUIN,PHONE(209),4 T!P # j p O BOX 388, STOCKTON,CA 9520 0 µ 3.v> /y/� y PERMIT EXPIRES 1 YEAR FROM ATEH� (Complete in Triplicte) O t Ll a� Application is hereby made to San Joaquin County for a permit to construct and/or install the work herei "scribed.This-applieeliortie a wt S n Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health rvOiT s. MinJob Address 22110 E Mili-CM Rmd City Linden Lot Size/Acreage3-2 AC-+ Lots Owner's Name pJi 11 i am Msandne Address `i9j 7 n H. Md 1 tm d Phone — — Contractor Ft a+er/Rud lder Addres 22110 E. Mi1tQD Road 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 fa Domestic/Private Cl Gravel Peck ❑ Tracy Type of Casing_ Specifications I.1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Inigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. —_ State Work Dona _ Well Destruction ❑ Well Diameter Sealing Material L Depth _ Depth _ Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo seplic system permitted if public sower is _ `SOIL $U1mBTT.T rY m= FOR SmTc SY91'F" M10) available within 200 loot.) Installation will "me: Residence—Commercial_ Other PM 7MT CMY AT IM C Number of living units: _ Number of bedrooms rn Jam- y Ve S Character of ao8 to a depth of 3 feet: Waist tabla depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments TPKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Properly Line LEACHING LINE Cl No. B Length of lines Total length/size PAYMENT FILTER BED ❑ Distance to nearest: Well Foundation Property LineR F C C-I ED SEEPAGE PITS 11 Depth Sirs Number -1:1N1 Y SUMPS LI Distance to nearest: Well Foundation Propett� Lie t ++4EPVICES DISPOSAL PONDS ❑ 1011 I hereby certify that I hove 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'+signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 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 .�.l�z-^"� Title: .- e^"11 Aff'^' Date: Z19k �&Z&V FOR DEPARTMENT USE ONLY Application Accepted by Data ie Ig Area Z Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 4-'Pe —a Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health PermiliServices 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 ��.-7 Fit EE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATF PERMIT NO. e,, (/ INFO y1 m . Ent]-]EIAFvrrxsr L (J24A EH tx y