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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .l ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 �- 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 Sectio 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address -� City /^�� 7 of Size/Acreage Q ner'a Name D eZ �`�S S ��af Address �� / GZ L/ Phone /3 1— 4,21V 77 Contractor Q. u fM�S Address !-V.��k I l Z [ License No.1,62 3 7-3 Phone `7 TYPE OF WELL/PUMP: ; NEW WELL 5;3 WELL REPLACEMENT ( DESTRUCTION Out of Service; Well O PUMP INSTALLATION fl SYSTEM REPAIR ❑ OTHER ❑ Monitc)ring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTORE WELL —ZAL' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 4�travel Pack ❑ Tracy Type of Casing _5VIE1 Specifications I'1 Public (-1 Other 171 Delta Depth of Grout Seal � Type of Grout I�rioalion —Approx. Depth W4astern Surface Seal Installed by _ / Repair Work Done UK' Type of Pumps f)VV T H.P. State Work Done _ ;Oewal v '—S�s+Qtkl Qat Well Destruction Well Diameter rr Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ CmmercI I _ Other Number of living units: Number of to / Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest. \�7/- Foundation Property Line YMENT LEACHING LINE ❑ No. b Length of lines X Total length/size FILTER BED C) Distance to nearest: /ell Founaatton Property Line a uE SEEPAGE PITS 11 Depth / Si:e Number APR19950 SUMPS LI Distance to nearest: Well Foun tion Property Lis �rn-rttt DISPOSAL PONDS ❑ / TA7U9AC 7Ti7 COUNTY I hereby certify that I have prepared this application and that the work will be done in accordance with � rj��Run6yLq ncMsFfitetp,taws, and rules and regulations of the Sen 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 pawn 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 o t e work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws 9f Califorrya." / The applicant for 911 requi i mplete rawmg on r e side. Signed �� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by \o Date Pit or Grot Inspection by G` ate L ?� Final Inspection bDate l� Q Additional Comments: rfv 6117&` — / -7/9 Applicant - e es to: San Joaquin County Public Health Services 0 (� Environmental Health Permit/Services �a f �r"'`J P ea sv .. l t 4 _/q 2 � � of W AQP 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201- 388 „„ppa�t v^ /T�� 7 INFO OVNT DUE AMOUNT REMITTEDCn ASH RECEIVED BY DAT EH 17-2t(REV.r;Sr 0 7 U '(�J ,/1 �P (! �l 0/�116 EH 14.76 't"3L . © l�o- 1 S �" 1 61 g qO �C