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APPLICATION 4 00W SAN JOAQUIN COUNTY PUBVC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469.342B , G S-3W-eb P O BOX 388, STOCKTON, CA 95201-0388 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 22180E Milton Road City IAiXXIBA Lot Size/Acresge}2Ac + lots Owner's Name RObeXt Bell Address 22180 F, MiltC91 Road _ Phone 887-3630 Contractor OWner/Btuldelr Address 22180 E. Milton Road License No. Phone 887-3630 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 Die. of Wall Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Pubk ❑ Other f1 Delta Depth of Grout Seal Type of Grout I I Irrigation —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 i Depth Depth _ Filler Material i Depth ,TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if pudic rower is (SOLI, SUITAB=TY STUDY FOR SEPTIC SYSTEMS DESIGN.) available within 200 feat., Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms M — 94- (Qn111a'Y AT 1fIIS TIME.�" - Character of cog to a depth of 3 feat: 94 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance TO nearest: Well Founds)dlt Property Links - --"�-- - - - -. LEACHING LINE Cl No. b Length of line f Toil length/size PAYMENT FILTER BED ❑ Distance to nearest Well Founogtion Property Lime LZMfn I ;: . SEEPAGE PITS 1 I Depth Siis 1 Number SUMPS, LI Distance to nearest: Wall Found*ion Propertytok ! 'IN GOUNTy DISPO§AL PONDS ❑ pliijU1, H rSCRViCES I hereby cenify that I haw prepared this applicatioi and that the work wil of done-M accoral,f, with iNV.I ` tC L ,Y ordinances, state laws, and rules and ragulatiorts of the San Joaquin County i \ I \� Home owner or licensed agent's signature conifies,he following: -I certify that in the performance of the Wolk for which this permit is issued, I shall not employ any person in such manner as to pecome fact to workman's compens Ilion laws of California." Contractors hiring or sub-contracting signature unifies the following: -I certify that in the performa{Eca of the work for which this permit is issued, 1 shall employ persons subfeci to workman's compenss- tan laws of California." i Thea applicant must Call for all required epuired inape,ctions. Complete tltawmg on reveres side. Signed K�� Title: �1NeY/'sr Isooyt— � Date: �M�•�a E ' 7 —7 l—► FOR DEPARTMENT USE ONLY Application Accepted by 7 Date Area Pit or Grout Inspection by Date Final Inspection Dy Date Additional Comments: Applicant - Return all copies to: an Joaquin County Public Health Services vironmental Health Permit/Services 5 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388FEE a^a �ZZZ INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED By DATE PERMIT N0. N . EN 13a. AIN ".m