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► APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYlqp�,.r ENVIRONMENTAL HEALTH DIVISION Rsc j, ll,- 445 N SAN JOAQUIN, PHONE (209)468-3420 JQN 1 P O BOX 2009, STOCKTON, CA 95201 gA () fn03 N JOA PERMIT EXPIRES 1 YEAR FROM DATE ISS�?ONM�N,�p hf N��'�INOES (Complete i Triplicate). i~.ALrHDIVISION Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3505- Ala,1U ler sue- City C Lot Size/Acreage /IIiV I1o1 U�"C�3 1�. 4ct-% S f. Owner's Name BP C) kr Yr>'��I�D(l(llEr Address Mpy F j(7 i1ct. ()H `+IQS-I u)9 Phone Contractor 10r Address License No._5Z2.10_Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O�+ 1 14oI 5onitoring Vel- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES >SO DISPraSAL LD. PROP. LINE mp,� o�rori FOUNDATION IDJr AGRICULTURE WELL � _ OTHER WEPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u Cl Industrial O Open Bottom O Manteca Die. of Well Excavation /G" Dia. of Well Casing Oomestie/Private ❑ Gravel Pack O Tracy Type of Casing PVC SL'/i - `f0 Specifications I'I Public rl Other n Delta Depth of Grout Seal 6 'bri4ype of Grout `--Y'1) I I Irrigation 18+ 0 a Approx. Depth I I Eastern Surface Seal Installed by o Repair Work Done U Type of Pump H.P. State Work Don _ Well Destruction O Well Diameter Sealing Material A Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 lest.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK O type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lames Total length/sue FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 1 I Depth Sue Number SUMPS LI Distance to nearest: Won Foundation Property line DISPOSAL PONDS O 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 certirws 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 tub-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 appli nt st call for all required inspections. Complete drawing on rover"side. Signed Title: ,%/df Data: FOR DEPARTMENT USE ONLY Application Accepted by Date 2'S-3 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMIT-TEDK H R CEIVED BY DATE PERMIT'NO. EM 13-24IREV.t,As) gq�� 9•� ll�-- 4- -93 93-019 AV ,