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w 1 APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES : ; :i: A k ENVIRONMENTAL HEALTH DIVISION x .•' `.. E. 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388,STOCKTON,CA 95201-0388 00 1 v .1 19 g 4 PERMIT EXPIRES 1 YEAR FROM DATE I_SSU ED (Complete in Triplicate) �f�l'Vi<QNR/,ENTAL HP-ALTH PCI<imd1ISERPIFs Application is hereby made to Sap Joaquin County for a permit to construct and//or Rules and the or herein describedSan Joaquin County Pubis made in lic Health Sompliance with man Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and B f t City S jaLK f jl Lot Size/Acreage _ ? .lob Address AA �r5 `` Owner's Name �`1 j,_V-1 A v►'ta.fr S1l��l Address S GDv f Phone r Z�� Conttactoft`C V+ `f iv.Address ( t�A License No. Phone TYPE OF WELL/PU P:` NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION Cl out of�rService Well C1 hakQltoring M�J.I. C3CiPUMP INSTALLATION SYSTEM REPAIR ❑ OTHER r r*�Oor+ 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 M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia_ of Well Casing Cl Domestic/Private Cl Gravel Pack7 ❑ Tracy Type of Casing- 'l Specifications 1.1 Public Other nDelta Depth of Grout Seal �r Type of Grout I I litigation s� Approx. Depth (� Eastern Surface Seal Installed by `� 1 Repair Work Done U Type of Pump H.P. State Work Done _ Naterial i Depth Wel! Destruction D Well Diameter Sealing y Depth ____ Filler Naterial k Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDITiON I I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.l A` Installation will serve: Residence_ Commercial — Other - Number of living units: Number of bedrooms t Character of soil to s depth of 3 toot: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearestWell Foundation Property Line VAN" LEACHING LINE 0 No. & Length of lines Total length/size s [n FILTER BED n Distance to nearest: Well Founoatron Property Line v' SEEPAGE PITS I I Depth Site Number SUMPS " LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenity that I have prepared this application and that the work will be done in accordance with San Joaquin county otdinances, stele laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: ••I certify that in the performance of the work tot 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 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 workman's compensa- tion laws of C itomia.'• The applicant ust 11 for of trod inspgctions. Complete drawing on reverse side,. - Signed Title: py`_e S Date: FOR DEPARTMENT USE ONLY Application Accepted by Date l p ! 5 Pit or Grout Inspection by Date C ` final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services i Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 FEE AMOUNT DUE AMOUNT REMITTED CK ' RECEIVED BY DATE PERMIT NO. ( Cl) INFO CASH }� 1 /0-.2 yqy neo y EM 14.20 t11EY.lie e1 6B a EM 14-20 ---+ter -w-