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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)458-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT_E IRES 1 11" FROM DATE ISSUED (Complete ill Triplicate) Application is hereby taadt to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with Batt Joa.4uin county Ordinance No. 549 and 1862 and the Rules and Regulations of San 3osyuin County Public Health Services. Job Address 3 1ia47V Ik Y CitY '�Z � +�L Fixe/Acrrage ,'T Ir Ownst's Name i�. t, _'^+t S L Add,ass C;Ql 2 e4k"f Phone y Conir2ttor _�z,1 t1,{i{. _Adartss ?�O, Ppy X'argeepLictnse No Phone TYPE OF WELL/PUMP: i NEW WELL G WELL REPLACEMENT C) DESTRUCTION C Out of Service Well .Gl ' PUMP INSTALLATION Cl SYSTEM REPAIR OTHER C 1tonlUoring Ilei) O ..y i DISTANCE 70 NEARST: SEPTIC TANK-77 SEWER LIKES �,_..:>,•.,_ DISPOSAL f1.fl• PROP. LINE y, FOUNDATION AGRICULTURE WELL `abTHR WELL PITS/SUMPS INTENDED USE TYPE GE WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' C7 industrial ©Ligan Bottom Cl Manteca Dia. of Wali t'tivaYiort, �- Dia. of Well Casing t l Dotrtestic/Priveta Cl Gravel Peck Tracy Type of Casinq.� Specifications 11 Public f other r! Delta Depth of Crtout Seal Type of Grout_ i. lrrit;atian 7 ,__Aoprox, Depth i I Eastern Surface s4whnst4lled by 'Repair Work Done + U Type of Pump H P. _ State V1" LS<dii'_ ' Well Destruction O Witi Diarnster ;, T BNlir'4 lris�terial i'Depth r•� Depth ' r, '�� rille Material i Depth _ , i TYPE Of SEPTIC WORK. NEW INSTALLATION'I i REPAIAiADDITtONDESTRUCTION I I (No septic system permitted it public sewer is . ��✓ available within 2W feet.) _ .�_.. Installation will wive: Residente! ComrlCerfwl��',; Nror: .t• - ' Number of living units: r Number of"bedr_ibms Character of soil to a depth of 3 feeti: ' Wetter labia d;0th SEPTIC TANK 0 ;Type/Mfg ._ p , Capacity No. Cam�wnrrteetts PKG, TgEATMfNT PLT.0 Method of Disposal Distar^iCe to nearest: Weft _ _ Foundation Propsity Line _. IIF LEACHING LINE 'lK"No. 4 Lrtngth of lines ��. f✓5 T�" � Total 109th/else FILTER BED LJ :Dista to nearest elL_,CLG_ FnundationProperty l ine�, _ � } a SEEPAGE PITS I I I Daptfi Sire _, Nurribsr _ t s SUMPS 0 Meletin neerO; Well Foundation 1 Propwty 0, i DISPOSAL PONDS of i i•• I hereby certify that I have prepar,;6 1Z appiicatinri and•that the work wits be done in accordance with San Joaquin county ordinances, state laws,;and' tines and regulation of the San Joaquin County ' Homs owner or konead agent's signatura candies the following: "I certify that in the performance of the work tot which this Pam vi is issued, I shelf not ampioy any person in such mannr as to become subject to,ivwkman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following:"I certify that in;ha performance of rhe work for which this permit is issued, I shall SMOCY parsons subject to workman's compsnsa- tion taws of California." t The applicant trout call far-40 r iwbdrin tions. CoripI*ts drawing on reverse side. _ t �i Signed "i �'•ky Title. Date: DEP 74th Application Accepted by Date ` Area ,Pit.or,Grout Inspection by_ Date. ---._ - - - --Fitvd Inspection.by- :iyete _. .AriditbrtaiJromrr+enta:� _ �. �i�,_.. `-.,f•„i'x '4rr.i''.,.� �Vf ., 1 Ap->licant - Return all copies to, San .70aquin County Public Health Services 1 Environmental Nealth Pertsit/3ervices - 445 N San Joaquin, p O sox 2000, Stkn, CA .95201OCK ! 'w "iNiCT A_OUNTatif111ri0UNTRQlulITJEt) � 8rt 1124 111lY.r r M st fA0 /�� t7 • rC1�+ > �ate EN t.•�e � r • r