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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ; ENVIRONMENTAL HEALTH DIVISION. 445 N SAN JOAQUIN,PHONE(209)469-3420 ` P O BOX 388,STOCKTON, CA 95201-0388 PERMIT EXPIRES 3 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 9-11I5.3 and the Rules and Regulations of San,Joaquin County Public Health Services. Job Address zrsI� City 9-mr-K—Al Lot Size/Acreage Owner's Name __ �'lA�rl41&^ Z' �� Address s� "" �� C)~�'�� Phone Contractor 94 1Iti + S VIV.Address License No. Phone lft-" 52-78'% TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT t1 DESTRUCTION ❑ Out of Service Veil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERMogitoring Well. ❑ A htiw0L "Aer-r- boil DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 1 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 L:. "Dia. of Well Casing C.) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 PublicYd Other n Delia Depth of Grour Seat r Type of Grout 1 I i Irrigation St'Approx; Depth ()Eastern Surface Seal Installed by "� 1 Repair Work Done U Type of Pump H.P, Stats Work Done_ Well Destruction ❑ Well Diameter See.lirg Material i Depth Depth _ Filler Material i Depth '�'� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is • available within 200 feet.) Installation will serve: Residence— Commercial Other : Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property tine (� 14 1 LEACHING LINE Cl No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founaatron Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line - 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 laws, and rules and regulations of the San Joaquin County Horne owner or licensed agent's signature certifies the following: '•I certify that in the pettormance 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 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 ifornia." The applicant ust all for d rred inspections. Complete drawing on reverse side.. J. Signed �� a�+�.� Title: P -e S t � Date: FOR DEPARTMENT USE ONLY 9 ,. Application Accepted by13L4� Date l / Area Pit or Grout Inspection by ` Date Final inspection by Da Additional Comments: DA t?Ire 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 FEE �90r INFO AMOUNT QtJS AMOUNT AEMI7IED CASHK I RECEIVED BY pATE''' PERMIT,NO. / ,6B , ,o,z yqy goy fH t4]a