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��--. APPLICATION - — SAN JOAQUIN COUNTY PUBLIC HEALTH ENVIRONMENTAL HEALTH DIVISI I11 � 445 N SAN JOAQUIN,PHONE(209)469- 4 P 0 BOX 388,STOCKTON,CA 95201-0 8Fm PERMIT EXPIRES 1 YEAR FROM DA (Complete in Triplicat 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 9-1111155.3 and the Rules and Regulations of San Joaquin County Public Health Services. I !(O� �� /�'1/� r iGEr City t Size/Acre e �� Job Address Owner's Name Ad I tl 11t'� -57 "1�1�T dress t �- Phon ! ;)-6 Contractor SPor1re14 A,1 Address ns- /r� S7�N�l� License No. �IZ_U� Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (1 DESTRUCTION ❑ Ou of Service Well ❑ PUMP INSTALLATION G SYSTEM REPAIR O OTHER Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE R Sat iQri FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications Q I"1 Public CI Other [1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth _ biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I 1 O 1J) �y! (No septic system permitted if public sower is P YMC "r available within 200 feat.) Installation will serve: Residence _ Commercial_ Other yCEIVE.D Number of living units: Number of bedrooms {� 2 7 1994 Character of soil to a depth of 3 feet: PR Water table depth ?1 SEPTIC TANK O Type/Mfg .&.,"Q I+�I IN C�--on No. Compartments ,1_1117 PKG. TREATMENT PLT. O PUBLIC Ham' L�T��}� Distance to nearest: Well C NTAL HEALTH�Wler�hod of Disposal (��r Property Lino \(� LEACHING LINE O No. & Length of lines Total length/size .\ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lino j\\ DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t n rules and regulations of the San Joaquin County v 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 shall not \i employ any person in such manner as to become subject to workmen's compensation laws of California.- Contractor's hiring or sub-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 workmen's compensa- tion laws of California." The applicant mqst call foryall r ired inspect' s. Complete drawing on reverse side. Q Signed X Title: 54MVI !? Date: v FOR.,DEPARTMENT USE ONLY Application Accepted by �r_ Date_ [(` Area Pit or Grout Inspection by Date Final Inspection by - Data S Z Additional Comments: — 3 cv - s Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 rn FEE )NFO AMOUNT DUE AMOUNT REMITTED C RECEIVED 8Y DATE PER NO_1 . EH 14-M