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• APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SE Z ENVIRONMENTAL HEALTH DIVISIO 445N SAN JOAQUIN,PHONE(209)469-3 AI P O BOX 388,STOCKTON,CA 95201-038 FA� PERMIT EXPIRES 1 YEAR FROM DAT ISSIIID (Complete in Triplicate) INR 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 a�ndd Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address —3731 //�VIeMJ-6c F6s City S' Ck TfdLC� Lot Size/Acreage Z+ p Owner's Name _ fJOA 'VIIItiles Address 1Px 9-3-93 J�ra`- gs208 ,.no �O ��Z Contractor I t-1,4t Address -Io l,1tgjz-'?1T7/License No. 6.5776 Phone ftL&I'7/L5 TYPE OF WELL/PUMP: J NEW WELL 1K WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Mel- ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION 7ie0/ AGRICULTURE WELL ffEL OTHER WELL—AZO—L WELL—AZO—LPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A ❑ Industrial ❑ Open Bottom u -Manteca Dia. of Well Excavation De. of Well Casing Cl Domestic/Private J6[Gravel Pack ❑ Tracy Type of Casing_ /wt Si 410 Specifications '0;10 f6r I'I Public 1.1 Other ❑ Delta Depth of Grout Seal 8V/ Type of Grout FO'Y"14K I I IrfDabon /a-Q Approx. Depth K Eastern Surface Seal Installed by cili"54"d boa: Repair Work Done U Type of Pump _— H.P. State Pork Done Well Destruction ❑ Well Diameter Z Sealing Material i Depth be.r 'n/ trtk V5_:* - r Depth_ 4"' Filler Material i Depth Ae tkrez >03 85—tia, TYPE OF SEPTIC WORK: NEW INSTALLATION ' I REPAIR/ADDITION I I DESTRUCTION I I (No/septic system permitted it pJ�, � �l available within 200 feet.)Installation will sane: Residence_ Commercial_ OtherNumber of living units: _ Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of DisposalDistance to nearest. Well Foundation Property LineLEACHING LINE ❑ No. g Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest Well Foundation Property LireDISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance , , 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 applect to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature cenifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subpct to workman's comp rnse- tion laws,of California." The applicant car II for MI ired inspection_ Complete drawing on rover" rover" spiga. //-- ®® 1 /JA Signed - Title: fF`1Kt�ptif i i�`6C2N rI9J!✓'04,1�; —�� OR DEPARTMENT USE ONLY Application Accepted by DateAm Pit or Grout Impaction DY ✓ —5�* Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services don 64/ Environmental Health Permit/Services 445 N.San Joaquin,P.O.Bax 388,Stockton,CA 95201-0388 a^ m FEEiq INFO A/AMM�O((U7]NT DUE AMOUNT REmiTTED M UNTREmiTTED CASH RECEIVED BY DATE PERMn NO. � EH a3 • tx(REV. 1.a) J1A..• L,/y EH 3.2a _ ��(•4/ Q / 6O / a