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APPLICATION SAN JUAIQUIN COUNTY PUBLIC HE HC ICES / ENV T RONMENTAL HEALTH DI I SYY �l<�� 445 N SAN JOAQUIN, PHONE (2000 � 420 � ✓� P O BOX 2009, STOCKTON, C �Q(` �} / PERMIT EXPIRES 1 YEAR FROM DATE'`3�bi�_ (Complete in Triplicaft*v Application is hereby made to San Joaquin County for a permit to construct and/ [ h application is made In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules an Joaquin County Public Health Services. Job Addrets 13 3y>?. C-- GrA '_^-,'-- --- City M#,NTr�A Lot �Size/Acreage a j q C. Owner's Name 'R.r-1,, , 401 r,rw-1 Address ._00-�- TI- iat-4 E IC1� Phone SQg(-7(og Contractor �w/�S�r Address License No. Phone TYPE OF WELL/PUMP NEW WELL F) WELL REPLACEMENT [-1 DESTRUCTION Cl Out of Service Well C1 PUMP INSTALLATION [1 SYSTEM REPAIR C] OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES V_ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ f] Industrial U Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing F) Domestic/Private O Gravel Pack O Tracy Type of Casing___ Specifications 1'1 Public I.1 Other (1 Delta Depth of Grout Seal Type of Grout I I IrrrOatron __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump — H P _--- _____.__ State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth (y Depth _ Filler Material i Depth /\ TYPE Of SEPTIC WORK: NEW INSTALLATION i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public Sewer is (� available within 200 foot.) Installation will serve: Residence -9- Commercial __ Other Number of living units: Number of bedrooms 3 Character of soil to a depth of 3 feet: SFFNI)� }RM Water table depth Zo SEPTIC TANK O Type/Mfg f�L L _- Capacity 45�_ No. Compartments PKG. TREATMENT PLT. O f / Method of Disposal _ Distance to nearest: Well -150 Foundation _(�_ Property Line 500 � LEACHING LINE LR' No. 6 Length of lines RU Ll'mac, Total length/sizeIIhiac FILTER BED 1) Distance to nearest: Well Founastron Property Line SEEPAGE PITS 11 Depth _Sire Number SUMPS LI Distance to nearest: Well /L�F u dation Property Line DISPOSAL PONDS O / I 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: -f 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 10 Wo(kmen's compensation laws of California." Contractor's 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 mu 11 for e11 to ed-inspections Complete drawing on reverse side. Signed X_ -1--*' _ Title: 1!05)yly Date: Al 7 _Y3 ('` FOR DEPARTMENT USE ONLY /f� Application Accepted by �iPt1Y-Ao_— _ Date Area �r V Pit a,Grout Inspection by Date Final Inspection byDau O( LS -173 Additional Comments: Appll,ant - Return ell copies to: San Joaquin County public Health Services Environmental Health permit/Services ' 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 INEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DAT PERMIT NO. EN ti 14 MEV.V e er NFA // v� �� -" 1 �� c3 a40(�F