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APPLICATION FOR Jas 00 Alk SAN JOAQUIN COUNTY PUBLIC E VIRONIMTAL HEALTH445 N SAN JOAQUIN, PHONEJQJ P O BO% 2009, STOCKTON1.PERMIT (Complete in TriplOne �33 A".Ucation is hereby made.to San Joaquin County for a permit to construct and/or instw the von ere le application is made in coWliance with San Joaquin County Ordinance No. 549 sad 1862 and the Rules and Regulations of Stan Joaquin CountypPULLiic Health S*rvices. .lob Address �� 'A;f/J)'o0 4el, City/ 7f+/�/ C'�/`f Lot 8 i ze/Acretvge Owner's Neff* TtY��A /1ArTx. Address 3-o-/ Gam, Z,4 rAre AjeA. Phone �i .4*q(->Zo yYy�9/ s Contractor nlVT�ir/ry 5D ice_Address 4600.49Ly( �rAf�r`e License No, Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRISCTION 0 Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Nell C7 DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP_ LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Bottom ❑ Manteca Dia. of Weft Excavation_ being C.) Domestic/Private O Gravel Pack ❑ Tracy Type of Casinq_ lB>G" 21ns I'I Public El Other n Delta Depth of Grout Seal AErc a t I I Irrigstion —Approx, Depth I I Eastern Surface Seal insioNed b, 5 go Repair Work Done L3 TV"of Pump H.P. State 1Hpre NOJQ SN Welt Destruction O Waft Diameter Sealing Material A Depth F1 0 $L1��F4 iu n'Jul"IT1•J� Filler Material ✓1, Depth MENTALHEA1Tm niVES 1 Depth SIO TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOITION i I DESTRUCTION I I INo septic system permitted if pubic Sower is rn available within 200 feet.) Installation will saw: Residence_ Comffwrcial— Other �a Number of giving units: _i Number of bedrooms �y Character of will to a depth of 3 feet: SA/r Water table depth �� a SEPTIC TANK 2f Type/Mfg e ceftr Capacity LA _ No. ConV*nrtlsnts 2- PKG. PKG. TREATMENT PLT.❑ Method of Dimposel Oistanca to rwareat- Wall Foundation s Property Lin* y4 LEACHING LINE QP No. 6 Length of tines 8 a Twol length/size O FILTER BED O Distance to nowast: Wall e!W Foundation ' _ Property Line '�S SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nww: Well Foundaiton Prop," Line DISPOSAL PONDS O I hereby certify that I haw prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin cmnttiy Home owner or gicsnsad agem's aigrtriturs certifies the following: "I certify that in the performance of the work for which this perms is tsauod, t "it 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 conifisa the fotlovAng: 1 tsrtlfy that in the performance of the work for which this permit is issued, I shall employ perwr k subject to workman's compactas. tion laws of Califomle.'• The applicant mustSM for s✓ required inspections. Complete dewing on reverse side. zp Signed x__ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Arna. �f Pit of Grout Inapsctlon by Date Final Inspection by Oates Addkbnol (:omrnsnte: Applicant - Returtt all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services V J 445 N San Joaquin, P O Box 2009, Stkn, CA 952 FEE Lf 2t INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVES)SY DATE PEF1MiT'N0. . •ser 13.241nN. -SN 114 Iry 1363 i 1 EH 14-M