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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SER I � µ f ENVIRONMENTAL HEALTH DIVISION (� # _ 445 N SAN JOAQUIN,PHONE(209)469-342 { r1` # P O BOX 388,STOCKTON,CA 95201-0388 PERMIT E%PIRES 1 YEAR FROM D TE Iib` (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 9-1 5.3 and the Rules and Regulations of San Joaquin County Public Health Services. A Job Address City Cot Size/Acreage Va • , Owner's Name Address Phone v Contractor r ass .J License NOA-5 r r+ Phone / ^� TYPE OF WELL/PUMP: NEW WEL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYST REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL Z OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREATo( Grout ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ifxcavation Dia. of W6taa�ll CCasing - CI Domestic/Private ❑ Gravel Pack ❑ Tracy g_ g'peor 7119Ra Br1 �/�. FI Public 1-1 Other 71 Delta t SealI I Inlgatio t _ Approx. Depth I IEastern nstalled byRepairWork Done U Type of Pump H.P. State Work Done _Wall Deswdtbn ❑ Wsll DiameterSealinDepth gAP.I yr,.,n��OUNTY Depth_ Filler Material a Depth PUBLIC HEALTH SERVICES TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I I (No septic ryatem parmn IFµ, ¢ sewer is available within 200 feet.) �\I Installation will serve: Residence'✓ll� Commercial ther Number of living units: _ Numbek dr of baooms Character of soil to a depth of 3 fest: Water table depth SEPTIC TANK ❑ Type/Mfg !�- Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method clDisposal Distance to rtaarest: I Ondation Property Line LEACHING LINE ❑ No. 8 Length of lines - - Total length/size v FILTER BED ❑ Distance to nearest: Well ouncatlon Pro It Lina v u SEEPAGE PITS 11 Depth /L) Sire i)�Aflt+r bar SUMPS LI Distancene to ar st: Well Foundation,,( Or/ Property Line 1, DISPOSAL PONDS ❑ 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: "I certify that in the performance of the work for which this permit is issued, I 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: "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 must ca for alf.requj[ inspect. s. Complete drawing on reverse �side. t� /J Signed Title: Date: }\� FOR DEPARTMENT USE ONLY Application Accepted by " ijl� Date �`s'—�1'—�11� Area /rryor Grout Inspection Date g Final Inspection by Data 2;-,-Z,5_' 7 VVVAdditional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 1 I Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 m iq •1INFO FEE AMOUNT D/U�E-� AMO,U(Nr^Ty REMITTED SH RECEIVED BY DATE �PERMIT'NO. • Er tar laEv. fn(nd*1 1 �Q� '/-}47�a� h!/Ilnl