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r APPLICATION !-3i�� V 6s 8S 5a SAN JOAQUIN COUNTY PUBLIC HE �[SV 1f§?WM 3 ENVIRONMENTAL HEALTH D VI3I0� $5 130 0 445 N SAN JOAQUIN, PHONE (23420 • 170 0 P 0 BOX 2009, STOCKTON, WI�M��_ PERMIT IRES 1 YEAR FROM (Complete in Tripli INV Application is hereby made to San Joaquin County for a permit to construct e v is application in made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Ru es an IFn Joaquin County Public Health Services. Job Address 865 E R o t h Rd _ C,tyF r P n r-h C n m�.ot Size/Acreage Owner's Namp a C i f 1 r: P r e L a ;� Address .1508 D f-prit R cl 14 a ii Y,,a,-d _.__. Phone Contractor C 1 a LI& �' Address_2L". [:h a r r C2 r License No. Phone'r _Phone' /1 TYPE OF WELL/PUMP NEW WELLx@xx WELL REPLACEMENT (-1 DESTRUCTION C' Out of Service Well 0 PUMP INSTALLATION C SYSTEM REPAIR C OTHER (; Ifonitoring Well U DISTANCE TO NEAREST: SEPTIC TANK., 1 5() 1 SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION ____ AGRICULTURE WELL —_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC4TIONS (I Industrial ❑ Open Bottom L1 Manteca Dia of Well Excavation_ 1 6 11 Dia of Well Casing tt I Domestic/PrivateXq Gravel Pack r1 Tracy Type of Casing__&L e.l... Specifications- -T=56 Cl 56Cl Public F; Other 71 Detre Depth of Grout Seal _ Type of Grout Q l_el F-14 11 Irripatl0n Approx. Depth I ; Eastern Surface Saul Insto4od by Repair Work Done U Type of Pump S u h H P. S — State Work Done Well Destruction 11 Well Diameter Sealing Material i Depth p(� Depth _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION ' I OESIRUCTION I I (No seplic system permitted if public sewer is \C1 available within 200 feetJ InslaNation will serve: Residence _ Commercial__ Other Number of living unite: Number of bedrooms Character of SON to a depth of 3 fest: _ ----Water table depth SEPTIC TANK O Type/Mfg Cmp,city_ No, Componrnents PKG. TREATMENT PLT.Cn Method of Disposal Distance to nearest: Well ._ Foundation == Property Line LEACHING LINE C1 No. 8 Length of lines _._ _ Total length/size FILTER BED CJ Distance to nearest: Weil T Foundation _ Property Line !�\\ SEEPAGE PITS 11 Depth Size_ _ Number SUMPS LI Distance to nearest: Well^ Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will b6 done in accordance with San.inaquin county ordinances, stale laws, and 'tiles and regulalions of the San Joaquin County Horne 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 shall not rxnploy any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following; "I certify th2i in the performance of the work for which this permit is issued, I shall employ Perri subject to workman's compensa- tion laws of Colifolms." The applicant all f aiArq u d ti C plata drawing on reverse side. Signed Title:V P C 1�i T k Well I n c Data: ?R O r t y'I FOR DEPARTMENT USE ONLY q Application Accepted by / _ L �! Ar Pit or Grout Impection by Datel 0!Q�r Final Inspe � Date Additional Comments: Aprll�c,ant. - Return all copies to: San .Junquin County Public Health Servlces�. ,t� 1�,�' f1� �x t Environmental Health Permit./Services / 445 N San Joaquin, P 0 [lox 2009, Stkn, CA 95201 90014 O INFO FEE ;AMOUNT DUE AMOUNT REMITTED ASH 6� L�}/- /jet RECEIvED/BY DATi PERMIT N0. r,H 13.74 tREV.t 1 s s> �'" G% 1 '" . /r.�,� �� 7 `� ��/ I' EH 14-20 t i3 -.0?/g3 1