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02/27/2006 08:26 464013P ENVIRONMENTAL Hr^I_TH PAGE 01 ,%OW APPLICATION "We SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 9,3-zl 1rq ENVIRONMENTAL HEALTH DIVISION - ^�e_9z 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to baa Jonqula County for a perwut to construct and/or ingtAll the work herein dcecribed. Thin application is made in cotfq/llsnce with pan Joaquin County Ordinance No. $L9 and 1862 and the Rules and Regulstione of Ban Joaquin County Public Health viServices. Job Address —a a� x, �/lute A& City Lot Hize/Acreage 1 43 Owner's Nome1111/ ... d4"1rdAL_. Addross Phone Cbnlra[IM AQQICSS. - License NOiiK_3 Phone .0112M j�dvli TYPE OF WELL/PUMP NEW WELL O WELL REPLACEMFN Cl DESTRUCTION D Out or service well D PUMP INSTALLATION O SYSTEM REPAIR () OTHER O Monitoring well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca~ Ole of Well Excavation Dia. of Well Casing f C Domestic/Private 0 Gravel Pack Ia Tracy Type of Casing_ Specifications Fl.Public I.1 Other (-I Delta Depth of Grout �eal Type of Grout V 1 1'Inlpauon Aporox. Depth 1 I Eastern Surface Seal Installed by } Repair Work Done U Type of Pump _ Ii,P. State Work Done _ VVp11 Destruction ❑ Wen Diameter Sealing IMat,erial i Depth Depth Filler Materials Depth TYRE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTTOIQINd I;dbl<9J%lem perMiTTa if public sewer is available within 200 lest l Installation will serve: Residence__L Commercial _ Other Number of living units: T Number of bedrop r Character of sod to a depth of 3 feel' � y Water table depth ,p l��rr'L No. Cornperfinents SEPTIC TANK O Typo%lUllp N��t7C,�.� %opacity PkG tREATMENT PLT. Cl Method of Disposal G Distance to nearest: Well Foundation y Property Line K1 LE*CHING LINE to No, b Length of lines _-— `^ T Total lengthtsize 1 , FILTER BED C1 Distance to nearest: Well Foundation ____ Property Line SEEPAGE PITS I I Depth Site Number L t Property Lina SUMPS 1_I Distance to nearest: Welt Foundation _ (� DISPOSAL PONDS O I hereby csnify that I hove prepaf9d this application.and that the.work-will-be-done iM.4W"9dtincg wltN San Joaquin county ordinances, assts Ism, end rules and regulations of the San Joaquin County II Moms owner or licensed agent's signature certifies the following: "I certify that in the performance of the work lop which this permit is issued. I %hall not employ any person In such manner as t0 become Subject 10 workmen's Compensation lawn of California " Contractor's hiring or subcontracting SI'gnetvre cerllfies the following: "I certify that in the perlormance of the work for which this permit Is issued, I shall employ persons subject to workman's cempensa tion taws of California " The ■ppllce mu call for all r ui e�InSPG ons. Complete drawin6 on revere cede. Signed X Title: � �.w7ZC Date. _ `A* ENT USE ONLY r� r ,.�"Area-_.,® � + — Apblicstlon Accepted by n Dete4f_ L Pit or Grout Inspection by Datg Final Inspection Dy / - ', / Data e Additional Comrnanta: Applicant - Return all cOptPA to: San Junquin Environmentalounty HenithuPnrmilt/Serhvlrrr lcen dd N 'Jan Jonqu4n. p 0 Bax 2009, Stkn, OA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RELEIVED DY DATE PERMIT N0. INFO CASH F/t U•i4 Ittfv . 51 r 0� �q i 37 - �7-9� �� M 1,125 ,]a