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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a4 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388, STOCKTON,CA 95201-038$ PERMIT LaIRES 1 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 Joaquin County Development Title Section-9-1110.3 and Section 9-111155..3 and the Rules and Regulations of San Joaquin County Public Health Services, Job Address 700 O ioLk C�7 xRrvs h' ' �� City 5 Ib�-i I� Lot Size/Acreage r-2 Owner's Name CA Ci F,/1 NS� Address. cX z o� :Phone 3rW Contractor `; I/taClr .L �Rf;I• Address -el S . .YeC7U. License No. '— TYPE o.TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M - DESTRUCTION Cl Out of Service Well O PUMP INSTALLATION G SYSTEM REPAIR_ 0 OTHER M; itoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — ter--FOUNDATION �']� r AGRICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation r` Dia. of Well Casing CI Domestic/Private Cl Gravel Pack7 ❑ Tracy Type of Casing_ Specifications 1'I Public Other (1 Delta Depth of Grour Seal Type o1 Grout I I lrrigauonL Approx. Depth KEastern Surface Sou! Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction © Well Diameter Sealing Material i Depth Depth _ Filler Material i Depth MEW 61,01—or TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAiR/ADOITION I I DESTRUCTION I t (No septic system permitted if public sewer is available within 200 lest.) Installation will serve: Residence— Commercial . Other . Number of living units: Number of bedrooms Y Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance t4 neatest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to neatest: Welt Foundation Property Line SEEPAGE PITS 11 Depth Site Number SUMPS Ll Distance to nearest:. Well Foundation Property Line - DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 for which this permit is issued, I shall no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cenifies 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 lion Iowa of California." The applicant at ca 'tor all fired inspections. Complete drawing on reverse side. 5� - � f Q C Signed x �r/ L Tide: 1—pr •CSIL �� Date: l FOR DEPARTMENT USE ONLY � Application Accepted by Date Area Pit or Grout inspection by Date Final inspection I Date Additional Comments: �� S Applicant - Return all copies to: San Joaquin Coudfy Public Health Services" 0 Environmental Health Permit/Services 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-11318 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PEAMI7'NO. M 9 g9 -z aye N_ • EM 17.2 IREV.vinyl /so Q' EK 71.7e