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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> 445 N SAN JOAQUIN,PHONE(209)469-3420 <br /> P 0 BOX 388,STOCKTON,CA 95201-0388 <br /> PERMIT =Mg 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> Joaquin County Development Title Section 9-1110.3 and Section 9.11153 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> C11355 355 'AIU+ 4whu�a Cit <br /> . Job Address y�1XiK-b n Lot Size/Acreage 5�2/0' x 127 <br /> Owner's Name 3&Me.,S lr� ' K,"1'9e.l ., r Address q�JS /�1_ I� f.Ile�y �'' Phone `Tt0 7 <br /> Contractor&I'll ELpjhyA4tj v) <br /> ddress A AM 4eri License No.ff2LZ&_q�PhotmlilC'7) 745-Z12 R <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well <br /> PUMP INSTALLATION G SYSTEM REPAIR O OTHER O Momitorimg Well N+ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLOPROP. LINE <br /> FOUNDATION ^' AGRICULTURE WELL OTHER WELL%�V V PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A <br /> 0 Industrial O Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private O Gravel Pack O Tracy Type of Casing PVC, Specifications <br /> f'I Public f"1 Other X pots Depth of Grout Seal &I Type of Grout P014)AM <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. StatsWo D <br /> Well Deanrctlon O Well Diameter Sealing Material i Depth <br /> Depth_ biller Material i Depth $-R /1Qf1kr4& . n J9 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING UNE O No. A Length of lines Total length/sue <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nownt: WON Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby comity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Hone owner or licensed&pant's signature certifies the following: "I comity that in the performance of the work for which this permit is issued, 1 shah not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cortifm 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 compen &- <br /> tion Iowa of California.,' <br /> The f 7edions. Complete drawing on reverse side. <br /> Signed Title: AA+84G;Tz- . Data: 10-17-24 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �"4Y0 Area <br /> Pk or Grout Inspection by Date �Q Final Inspection by O � Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> to <br /> • EN 1}rt 111!1/.IiwSi � � a <br /> EH m4a1 <br />