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APPLICATION SAN JOAQUIN COUNTY PUBLIC ENVIRONMENTAL HEALTH DIVISIONVICES 3S 6 445 N SAN JOAQUIN,PHONE(209)469-3420 > / P O BOX 388,STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE MU— (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. Job Address City Gr /yl Lot Size/Acreage.- / /EE✓ M �j ?f ne Owner's Name / � . Address ( j ;'T fCr:.., Phone ,rte y r •? . _. ContractorT •< < r`-. 3 ] Address License No. 7 % Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION G 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dia, of Well Casing Cl Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing_ Specifications I'I Public 1-1 Other (l Delia Depth of Grout Seal Type of r-ma I I Inigauon _Approx. Depth I I Eastern Surface Seal Installed by D Repair Work Done G Type of Pump H.P. State Work Done_ KtULIVE Well Destruction ❑ Well Diameter Sealing Material A Deyth 111 I- 6 1994 Depth _ tiller Material & Depth Ill]IN iNTy TYPE OF SEPTIC WORK: NEW INSTA LATION I I REPAIR/ADDITION 1 I DESTRUCTION 11 (No septic system 1184iEALWM18gJKgCES � r ( /� available withiff"RINWENTAL HEALTH DIVISI N Installation will serve: es nci r'Comr7lerc Other Number of living units: _ Number of bedrooms Character of wit to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to newest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sirs Number SUMPS LI Distance to newest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I he" prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawa, 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, 1 shall not employ any person in such manner as to become subject to workman's compensation Is"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 persona subject to workman's compense tion laws of California.,. The applicant must call for all required inspections. Complete drawing on raver" side. SignadJ(1' 1_ T 'r• '�. ./.�/ Tint. - . y r-/,.:;9//i Date: 7 - C-� '1/ FOR DEPARTMENT USE ONLY Application Accepted b Z�_T, a✓'-� Date ^ " Ana �� y Pit or Grout Inspection by L Date Final Inspection by Data Additional Comments: Applicant - Return all copies to; San Joaquin County Public Health Services Y Environmental Health Permit/Services 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388 P l FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED By DATE PERMIT NO. n F CASH i . fit?24 mtv.vel ^L: w 4-aa S•P