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APPLICATION t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P 0 BOX 388,STOCKTON,CA 95201-0388 PERMIT IRES I YEAR FROM DATE ISSUED (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 k Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations o�f/San .Joaquin County Public Health Services. Job Address 2 43 1 M&R.(P l)S f� PD . City ;t_0_' Lot Size/Acreage - I / A Owner's Name Q� t Address P.O • a©K. A©,n 10 Phoma • I Contractor SP�C.�2unn L Address cS o 5 E J� Y✓P LE SG.License No.6 2� Phone —S71--L- TYPE S1---'TYPE OF WELL/PUMP- NEW WELL ❑ WELL REPLACEMENT n, DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑1 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES AJ 4 DISPOSAL FLD. AJIQ- PROP. LINE*'AW FOUNDATION AGRICULTURE WELL ■ __ OTHER WELL_2CLL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ij L1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation= Dia. of Well Casing i Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. RTC, Specification- I'] Public OthuetrO�t��,rO Delta Depth of Grout Seal �.3 Type of Grout I I Irrigation �L Approx. Depth Eastern Surface Seal Installed Fby Repair Work Done U Type of Pump H.P. 'State Work Done Well Destruction ❑ Well Diameter Sealing Material A Depth F Depth _ Piller Material i Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sower is R available within 200 feel.) Installation will serve: Residence- Commercial T Other �+ Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity € No. Compartments c3 PKG. TREATMENT PLT. ❑ !3 Method of Disposal Distance to nearest: Well Foundation s Property Line r 'a LEACHING LINE ❑ No. S Length of lines Total Length/size FILTER BED 0 Distance to nearest: Well Foundation " Property Line :I SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS O ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state larva, and rules and regulations of the San Joaquin County 1 Home owner or ficensad agent's signature certifies 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 subcontracting 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 applic u �coilf �roro�di �uons. Complete drawing on reverse,side. � Signed � g Title: Data: 4 441 FOR DEPARTMENT USE ONLY, 1 Application Accepted by - Date Areal Pit or Grout Inspection by Date Final Inspection by _ Date Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health PermiE/Services 0 S 445 N.San Joaquin,P.O.Box 388,Stockton.CA 95201-0388FEE / INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EK 13.241 REV.it A SI '-7 L'� LIf -e El+,u.m t�