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_ APPLICATION ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERI/I I D - ENVIRONMENTAL HEALTH DIVISION F�J 445 N SAN JOAQUIN,PHONE(209)469-34 0 P 0 BOX 388, STOCKTON,CA 95201-038F1 r PERMIT EXPIRES 1 YEAR FROMDATE 19M (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. �Sc A lw. ' Job Address 2a�I ) � ��' ' Owner's Name Lvg LA AIK.. '� Address �2 i 11`Z I UA--- R-771 j Phone �3 3�C(,sIS I GA t R�j3 Contractor ��P Address �� 1 1 License No. Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out o1 service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR, 0 OTHER ❑ Monitoring Well 0 ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS U r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� ' ❑ Industrial 0 Open Bottom ❑ Manteca Die. of Well Excavation pGjlNd�hbl 4yrig n CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ E�^SN�¢1 r icatur `ap�� I'I Public EI Other fl Delta Depth of Grout Seal MM�'QPa� GJ' I I Irrigation _Approx. Depth I I Eastern Surface Soul Installed by W! 6 1994 ' Repair Work Done 0 Type of Pump H.P. State Work Don44 IV70 I E Well Destruction Material A Depth SA on ❑ � Well Diameter C. - Depth_ Filler Meterial i Depth H DIVISION TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if pudic sewer is s� available within 200 feet.) Installation will serve. Residence k Commercial_ Other Number of living units: -Number of bedrooms ':2. ^! ' Character of Soil to a depth of 3 feet: s/� /y id Water table depth fc SEPTIC TANK Ilii' Type/Mfg I Capacity'Zj2-0�-C—L No. Compartments PKG. TREATMENT PLT. ❑ ! Method o1 Disposal r Distance to nearest: Well-�6 6 oundalion Property Line �. LEACHING LINE j2f No. 6 Length of lines e?�, ~'' r Total length/size / J FILTER BED C1 Distance to merest: Well Foundation 10 y— Property Lin (2.f SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearot:- WON 11C Foundation Property Lim - ' DISPOSAL PONDS ❑ r - 1 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 Sen Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fa which this permit is issued, I shell not employ any person in Such manner es to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: 'Y certify that in the performs a of the work for which this permit is issued. I shall employ persons sublect to workman's compensa- tion taws of Californ The applicator call for NI f uired ins , do . Complete drawing on reverse side. n ' Signed Title: � '-- Date: '7` --f fl i t FOR DEPARTMENT USE ONLY �y Application Accepted by Date Area ' Pit of Grout Impaction by Date Final Inspection Dy Date� Additional Commorits: Applicant -'Return all copies to: San Joaquin County Public Health Services Environmental Health Perunit/Services 445 N.San Joaquin,P.O.Box 388,Stockton.CA 95201-0388 1FEE AMOUNT DUE AMOUNT REMITTED C H RECEIVED BV DATE PERMIT'N0. 1 EO 'EMU-]4IREv,veep bo a IN 14 fd