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a-S Hp,S APPLICATION 3.o Hr[s 7717-At-(2.o Ek7g-A keS .Q/LLE) . v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P 0 BOX 388,STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) Oo( - Z30�t�3 Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.'Ibis application is made in compliance with San Joaquin County Development "`e Section 9-1110.3 and Section 9-1 5.3 and the Rules and Regulations of San Joaquin County Public Health Services. 1o9tn) � �yI�J #358 - Job Addrea E- ity Lot Size/Acreage O.errser't Neme •`�- t.OY�u-+ r Address'. - - f • ..-.._ - p 6. f Sa YU I ` sZ e ?t/1S r+s,Rass.sl ,/.1• nco�tiJ �..J Me . -- ••-• (v7Z none �romrauor __ _ cense No. _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service well , ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,❑ `r OTHER ❑ Monitoring well [3 DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES t ,DISPOSAL FLO. PROP. LINE r 1 FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -❑ Industrial ❑ Open Bottom •❑ Manteca Dia:of Well Excavation Die. of Well Casing Ca Domestic/Private f ❑ Gravel Peck 'i ❑ Tracy Type of Casing_ r Specifications- 1'1 Public 17 Other r fl Delta Depth of Grout Seal Type of Grout I I Irrigation -Apii Depth I I Eastern Surface Sent Installed by I - Repair Work Done 0 Type of Pump H.P. State Work Done_ rt Sealing Material &'Depth t' W � Well Destruction r Wed Diameter 1 r \ ` Depth �7AV---- Filler Material &,Depth C TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public s1twer is C ` available within 200 laat.l Installation will serfs: Residence_;_Commercial Other f Number of living units: _ Number of bedrooms ' Character of wit to a depth of 3 feet: fT - Water table depth SEPTIC TANK ❑ Type/Mfg C Capacity - No. Compartments 7� PKG. TREATMENT PLT.❑ Method of Disposal 1 Distance to nearest:', Well Foundation Property Lina C • __— _- a�NpAM Mu•aS�{e LEACHING LINE ❑ No. 6 Length of lines ' Total length/sizeRECEIECyfCowN1 nearest: FounoatProperty 1g9 FILTER BED - ❑"Distance to arest: Well I ion PLine tfE,F NP.1 16 1994 SEEPAGE PITS I I Depth. Size Number SM4 jeftQtiff COUNTY SUMPS- LI -Distance to nearest: Well Foundation Property Lina of 1141 IC +. N TH SERVIf;j_'S DISPOSAL PONDS o ENVIRONMENTAL HEA 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 i 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 laves of California." t ,T The applican must II t required inspections. Complete drawing on Jreverse side. SignedK "'�. -•-^-^ Title: (Jt_tf-Jl��/ _ .Date: 1 FOR DEPARTMENT USE ONLY ' Application Accepted by C Cd•BYY�{Y.� Date Area Ph or Grout Inspection by - - Date _ Find Inspection by Data • c!y Additional Comments: Appl leant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services, 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201.0388 /" , (, X,D 2/j FEE INFO 'AMOUNT DUE AMOUNT REMITTED K N RECEIVED BY DATE V �P'EE MIT NO. I Fj . of r-N lr� �A_M)EM 13-24 rRV.I/M]I y � I • �n