SITE INFORMATION AND CORRESPONDENCE_CASE 1

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; I APPLICATION SA4l.LAQUIN COUNTY PUBLIC HEAT T , aVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ' P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED bore 3 , I (Complete in Triplicate) Application is hereby made.to Saa Joaquin County for a permit to construct and/or instal_L the work herein described. This application is sade in ccmpliance with San Joaquin County Ordinance Ho. 5L9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 4 - 2�O SS QC•�C Job Address _ 41+I t f' " City_ M �0,%+C ' Lot Size/Acr eage S _ P.!13OxlG0 Owner's Name ( V1 ' t �y f`C�iIIC�S Address �G LCOIL'i,.: t , Tknr4c.t (kX535 Phone C 94 -V f�, 1 �rtt:ir'CliMt'_4}e;� Cf}, �T57`r•� 7 Contractor "� r Ch t 1 Address PD Q Z� a�c�oC'��aYv License No. { Z� Phone 952- 5552 TYPE OF WELL/PUMP: NSW WELL © WELL REPLACEMENT Ci. DESTRUCTION 0 Out of Service We ` PUMP INSTALLATION u./ SYSTEM REPAIR ❑ 6drrr4 THER Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK } S SEWER LINES 7 /�� DISPOSAL FLO. AJ 4 PROP. LINE SQ FOUNDATION Z r AGRICULTURE WELL G OTHER WELL SQ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i r C1 Industrial 0 Open Bottom C1 Manteca Dia. of Well Excavation 11 Dia. of Well Casing Domestic/Private it LJ 0 Gravel Pack ❑ Tracy Type of Casing_5ek U Q 1i C Soecstlicattons Sr'�r Il Pt,blic II., 0 her Cl Delta Depth of_Gtout Seal _� Type of Gfout �•��C�r"i'�� I i Irrigation c �(Apprax. Depth l(X Eastern Surface Seal Installed by ��"��r•�+ F�+��^6� ^�a.✓�1 Repair Work Done 0 Type Pf Pump H.P- State Work Done_ Weil Destruction 0 well Diameter Sealing Material i Depth Depth Filler Material. 4 Depth kstailation PE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAIRIADOtTION I I DESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.) 11i will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of tai) to a depth of 3 feet: Water table depth F SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Oisposal. Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of tines Total length/size FILTER BED jt,�I 0 Distance to nearest: Well Founaation Property Line SEEPAGE PITS t 11 Depth Size Number SUMPS �i LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C] 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 slit-contracting signature canifies the following: "I certify that in the performance of The work for which this parntit is issued. t shall employ persons subject to workman's compansa- tion laws of California." The applicant must call for a requir d inspections. Complete drawing on reverse side. Signed X Title: I,•� t � U Data: / ��k� FOR DEPARTMENT USE ONLY J� Application Accepted by `-'� ' _ Date f'r Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return- all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 INFO AMOUNTDUEAMOUNTREMITTED CAST+ RECEIVED By GATE PEPMIT?NO. nage 13.4 EH Q-t.tnEv.,..sr 1 EH ii.m f �