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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 > ' P O BOX 388, STOCKTON,CA 95201-0388_ .: PERMIT F"IRES 1 YEAR FROM DATE ISSUED " I (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. 'd. 5- E Job Address sl— Fy,t 1"84 1 5 t Z l City d L � -Lot Size/Acreage i ;1 6I 111, 13 0 P Owner's Name Cm PPOJOCTS Address Sail y q Phone I S"��7 f✓� rancho Covdovq (- Contractor { tr it j;n NV.Address 1?�• SDI< ! Q ti 714License No. 7.2 b„ �Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Ul DESTRUCTION ❑ Out of Service Well C7 i PUMP INSTALLATION G SYSTEM REPAIR CI F OTHER • Mo itorl well ❑ f sc,� 0)4; 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 L1 Industrial ❑ Open Bottom 0 Manteca Dia. of Weil Excavation Dia. of Well Casing EI Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ ' Specifications l'1 Public 1-1 Other n Delta Depth of Grout Seal d Type of Grout -poi-C loll I I Ifrivalion — Approx. Depth I)kEastern .Surface Seal Installed by_� �j►"y141 _ Repair Work Done U Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRrADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence— Commercial_ Other i ti r; 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Founaanon Property Line k SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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, end rules and regulations of the San Joaquin County r 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 shell 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: "1 certify that in the performance of the work for which this permit is issued, I shall smplay persons subject to workman's compensa- tion laws of Cali n The applicant us all of all r redc to mplete drawing on r se side...1 k rll t Signed Title: Dste: .... FOR DEPARTMENT USE ONLY Application Accepted by ' Date Ares Pit or Grout Inspection by Date `7 / Find Inspection by + Date �f Additional Comments: Applicant - Return all',copies to: San Joaquin County Public Hearth Services Environmental Health Permit/ServicesQ l 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388FEE ! a CK INFO AM"OOUNTT DUE AMOUNT REMITTED /9CA/SH RECEIVED BY /DATE �PyERNIM N0. . EN 172 INEv.fiA5� R I (� lcJ{O� Lrn� O 7- l7QjO a ' EH 1�•7a .f f _ - f 'rV+rT rT rT'rri r"5 m r r^! r `r r-rr-r Tr