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ttkd !.d fivr- S��[�l3 tx � APPLICATION ` I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES !S "a-d AS' ENVIRONMENTAL HEALTH DIVISION NCEt1s re1e.!!� . 445 N SAN JOAQUIN, PHONE (209)468-3420 was Nwrs - i P 0 BOX 2009, STOCKTON, CA 95201 ►-��/ �d as Y. d-s. ' PERMIT EXPIRES 3 YEAR FROM DATE ISSUED wcllwaSwFdrewti o>< (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work hefiin descr Thier G application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulatioi;8� oT+ cQSa I Joaquin County Public Health Services. 7 --F-fa -g r*-ft_4 N I Job Address 30[13_ E �>ramm�IC �� City!St hdb� Lot Size/Acreage. ( r' Owner's Name Stoc l.,sm RN L Address So 4 3 1E Uri rna.f, UhM 19 Phone Contractor VX+04mkl 4{3 Address 1,b &$ 5 � License No. *�SM18 Phone 'S TYPE OF WELL/PUMP: NEW WEL ❑ WELL REPLA MENT Cl DESTRUCTION ❑ Out of Service Well. ❑ I PUMP INSTALLATION SYST REPAIR Ll OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION A ICULTURE ` ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR NSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca ia. of Well excavation Dia. of Well Casing C`1 Domestic/Private ❑ Gravel Pack L7 Tracyh'r Typ f Casing_ Specifications I'I Public =.1-1 Other ❑ Delta Depth o out Seal Type of Grout y, I I Irfigation _.Approx. Depth I I Eastern - ,Surface Seal In ad by 0 ' .Repair Work Done U Type of Pump @ ' State Work Done _ Well Destruction © Well Diameter `" sling Material e. Depth :3E " Depth + Filler Material 3 Depth ' •YPE Of SEPTIC WORK: NEW INSTALLATION i I' REP_AIRIADDITION 1"1 rDESTRUCTION I I INo septic system permitted it public sewer is s,aKK available thin 200 feet.) Installation will serve: Residence_ Commercial" Othe _�_> ,-SAIN� M r11- Number �Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Clam Water table depth SEPTIC TANK.. 13 'Type/Mfg Capacity IS No. Compartments 3 # PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation 140 Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: #Well Foundation Property Line r SEEPAGE PITS I I Depth Size Number SUMPS it 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, 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 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 terrifies the following: "I certify that in the performance of the worts for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I{ The appli t call uired inspec ' ns. Complete drawing on reverse side. Signed Title: _ 4 , _.._. Date: S_(D EOR PAYMENT USE ONLY Application Accepted by _[ rSAAA - -a 1�^;?b&w Date *��3 Area r , Pit or Gr I tion by Date Final Inspection by Date__ 41 3 } Additit EMents: 76 f Applicant - Return all copies to: San Joaquin County Public Health Services r/ 1d Environmental Health Permit/Services X445-N,San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NQ. R. fHt4.�INtV.��nsl I ' �d S r��