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APPLICATION SAN.JOAQUIN COUNTY PUBLIC HEALTH SF7' ENVIRONMENTAL HEALTH DIVISIO 445 N SAN JOAQUIN,PHONE(209)469-P O BOX 388,STOCKTON,CA 95201-0PERM T EXPIRES 1 YEAR FRO D T (Complete in Triplicate Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.]ills app tcatton u i5de m 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 Add,-- 3 2�'r 5 6: O�T �� City M�K T-C C 4 Lot Size/Acreage 2-14 A G V le�' Owner's Name In !tit-P F-l e 1I 4 Address o o R`s K- 9= Phone S 2 " 11 -7 1 Contractor_ bw 'r-f-'7_ -- _ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Ifel1 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 CI Industrial 0 Open 8anom 0 Manteca Dia. of Well Excavation Dia. of Wed Caging El Domestic/Private Cl Gravel Pack7 0 Tracy Type of Casing_ P ` Me I'l Public 1-1 Other n Delta Depth of Grout Seal � {,r�/Grxma t I Irnuation Approx. Depth I I Eastern Surface Seal Installed by �i CCl V C Repair Work Done 0 Type of Pump H.P. State Work Done MAY 31 Well Destruction ❑ Well Diameter Sealing Material i Depth ra R, rnngillhi-NUNTY Depth Piller Material A Depth PLJBLtC i•IE stiTiiV'�4l1V'�1�i TYPE OF-SEPTIC WORK: NEW INSTALLATION 16rIEPAIRIADDITION I I DESTRUCTION I I IN I W. r is \) available within 200 feet.) N Installation will serve: Residence-!=- Commercial— Other {� Number of living units: Z` Number of bedrooms tv Character of sod too depth of 3 feet: 'FA-rt O Lo/k.+h Water table depth Z SEPTIC TANK 0' Type/Mfg L G Ort L. Capacity l�'1'tao No. Compartment PKG. TREATMENT PLT,Cl 1 / Method of Dir/posal 1 rte' BAS- Distance to nearest: Well Foundation J O, t _ Property Line LEACHING LINE Cl No. &Length of lines total length/size FILTER BED �S� Fr Dist nce to nearest: Well l a Q Founaation I o -�" Property Line— q Xf�4L 1=1 Dist r w_ir'1.._ ulf _ � vALU� �-a a*�� SEEPAGE PITS I 1 Depth ,Cl Sire�� ,�.4- Number _ SUMPS PC Distance to nearest: Well.G`oc, , Foundation 14 Property Lina �d DISPOSAL PONDS C) 1 hereby cenify that 1 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 San Joaquin County Home owner or licsnsad agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mannar 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 laws of California." The applicant all f a req r tions. Complete drawing on reverse aide. Signed Title: N Deis: J 3 FOR DEPARTMENT USE ONLY Application Accepted by ---- - _ Date fes Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: ' � +'� �u l --- `� D _/�A- 64e.--,.r V-e,,;� Applicant - Return all copies to: San Joaquin County Public Health Services I Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 tFEE AMOUNT DUE AMOUNT REMITTED ASS RECEIVED 8y DATE PI RMIY'Nt). ops 5,1 x EM,1•]g �