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'< E 1.0 los 95- .),3-0 5-•),3-0 clat • )70r dlw i APPLICATION(/� SAN JOAQUIN COUNTY PUBLIC HEF#MIA134 T 3 ENVIRONMENTAL HEALTH D %�� 445 N SAN JOAQUIN, PHONE (220 P O BOX 2009, STOCKTON,�%�2 (Complete in Tripli�•/�j� Application is hereby made to San Joaquin County for a permit to construct N. e v �efwt.i,p application is made in compliance with San Joaquin County Ordinance No. 5+9 and 1$52 sad the Ru es an ibrr Joaquin County tLblic Health Services. Job Address 865 E Roth R rl _ C.tvF r a n r h i, a m riot Size/Acreage 7 S Owner's NamJ a c i f i C P r e c a ss _ Address 3508 DPPat R ri N a .r ur a r r1 Phone 1 Contractor C 1 El>;'L gl 1 Adores � n? 4 _ E_ C�T�F � g r License Na. -; 1��g� Phone TYPE OF WELL/PUMP: NEW WELLx®XX WELL REPLACEMENT 7) DESTRUCTION ❑ Out of Service Well D LVNIF I PUMP INSTALLATION C SYSTEM REPAIR C OTHER C Monitoring Nell C7 DISTANCE TO NEAREST: SEPTIC TANK.f.1 3Q r SEWER LINES DISPOSAL FLD. PROP_ LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (I industrial D Open Bottom D Manteca Dia. of Well Excavation _ 1 rr r Dia. of Well Casing rt hl DomesticlPrivate x� Gravel Pack C7 Tracy Type of Casin -_P 1 g_- Specifications Cl Public I i Other fl Care Depth of Grout Seal Type of Grout !. F I I Initiator _ Approx. Depth 1 1 Eastern Surface Saul Installed by Repair Work Done LJ Type of Pump 511 h H P. S __ _ — State Work Done Well Destruction D Well Diameter Sealing Material &Depth Depth _ Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No se lis system permitted if Public sewer is available within 200 feet.) Installation will serve: Residence T,. Commercial __ Other _ Number of living unite: Number of bedrooms Character of spa to a depth of 3 feat: Water table depth SEPTIC TANK O Typo/Mfg Capacity_ No. Compartments EKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well . Foundation — Propeny Line .EACHING LINE ❑ No. & Length of lines 4_ Total length/size 4LTER BED n Distance to nearest: Well Foundation _ Property Line iEEPAGE PITS 11 Depth Size Number iUMPS 1.1 Distance to nearest: Well , Foundation Proterty Lino )ISPOSAL PONDS ❑ -•-ter -^^r • o •o o yropa,v rrns jppucauon ano tnat the work will be done +n accordance with San .inaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signacure certifies the following: "I csrtity that in the pe,formance of the work for which this permit is issued, I shall not employ any person in such manner ns to become subject to workmen's compensation laws of California." Contractor's hiring or sub -contracting signature codifies the foltowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persofs subject to workman's compensa- lion laws of California." The applicanA51aU f9tal! rlqu dpi tiol, CgIliplete drawing on reverse side - Signed v v��y� igned Title: - p Clark We] I. Inc Date: ? Application Accepted by Pit or Grout Inspection by Additional Comments �p C/ W-fIA�f.__� ADT-.1nt - Return all copies to DarE PMiT'NO. ER LVNIF I rFE-E AMOUNT DUE FOR DEPARTMENT USE ONLY Date Tl 0 -"y` J I Final Date V �%l San Joaquin County Public. Health Services, f 2; //-r Environmental Health Permit/Services 1 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 n�j/ /ti • EN13-24(REV.1/AS$ EM 14.28 �'3 --./i3 AMOUNT REMITTED ASH RECEIVED BY DarE PMiT'NO. ER LVNIF I • EN13-24(REV.1/AS$ EM 14.28 �'3 --./i3