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APPLICATION E —� ---- -- _ SAN JOAQUIN COUNTY PUBLIC HEALTLGENVIRONMENTAL HEALTH DIVI445 N SAN JOAQUIN, PHONE (209)P 0 BO% 2009, STOCXTON, CAPERMIT EXPIRES 1 YEAR FROM DAT i':cmplete in Triplicate/ Application Is hereby made to San Joaquln Count. for a permit to construct and/or instal` the work herein described. This application is made in compliance with San ,;ce4.: •ounty Ordinance Vo. 549 and '862 and the Rules and iegu:atlons of San Joaquin County ^^Public Health Services. (� / Job Address -e-� G- (� a S�-° -.�c C;y `T-c1'V's Lot Size/Acreage L-� T I r Owner's Name ��s^�v>k i..l Access Sf3vvv.�Zn- Phone 2.Z_-A Address ^ 4, Contractor l--• <i'• l -�—,c I �.! •1� _ - ' � License no. 3'�'�ji ?gone i �• ` TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT F111 DESTRUCTION G Out of Service well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION --'CULTURE WELL OTHER WELL PITSiSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wed Excavation •" ' 1<018sof Well Casing C1 Domestic/Private ❑ Gravel Pacx ❑ Traci Type of Casing__�T;_,,Spectlldarc I'I Public 11 Other 11 Der,z Depth of Grout Seal •+., "j`•pj Of Grout I i Irnuduon Approx. Depth 11 Eastern SuHace Sedi Installed by ^^r Repair Work Done U Type of Pump R.P. _ Si, -Work' i, Work;O.OneJ " Well Destruction ❑ Well Diameter Sealing Material i Oepth LGl'J r��;.,-, T Depth Filler Material L Depth TYPE OF SEPTIC WORK. NEW INSTALLATION 'A- REPAIR'ADDITION i I DESTRUCTION I I INo septic system permntad II public sewer is 04 2 Instillation will serve: Residence Commercial OU ��'' ��p available wlmin 00 leet.lter -s-�— Number of living units: _ Number of bedrooms ' , Character of sod to a depth of 3 feet: �..3v- 7/hN✓1 Water table depin ��• ` SEPTIC TANK �..Type/Mfg G._ovg^ 01it C Capacay4 6z-so- No. Compartments PKG. TREATMENT PLT. G Distance Method of Disposal m nearest: Weu � Foundation � Property line 4 rC LEACHING LINE 0- No. & Length of lines -l7 t•IU Total length/size FILTER BED Cl Distance to nearest: Well Foundation 'fir' Property Line Ine- _ t SEEPAGE PITS W Depth Size (c </ _ Number a SUMPS LI Distance to nearest: Well i!`� • Foundation •7 r Property Line /00 DISPOSAL PONDS ❑ I hereby certify 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 licensed agent's signature urtlfies 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 workmen's compensation laws of California." Contractor's hiring ar sub-contracting signature certifies the fallowing: -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 must call rI require Ions. Complete drawing on reverse side. Signed X f� m mn�f� Title: 0LLd 11 L--7Z Date: �/^ .•�( -�i y l^ FOR DEPARTMENT USE ONLY q 7 Application Accepted by -��`� Date III Z I rea `" —Z r Grout Inspection DY �" � �te not Inspection br1ty' A Z,�G Zee e Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services I 445 N Sao Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CA EC IVEO By DATE VERM,IIT NO. •iM ill-low rre"I EH ia.m