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ADPL•I C W T nN SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Countty/Public Health Services. Job Address ` '� �""'jal"r "/�- nd6'rte ;PoJ /City `a-7410Lot Si ze/Acreage /3 4C*,C- Owner's Name r!rlxs 4�S4fa'&t-- Address 3-2s- A�. W'Ce'� LAve,swk me," Phone(StA7��°'�L¢2� ContractorT&*'t -&1eIJ 6-&4rhn&• Addresses E•�zstaar� AMav4e_c.a.- License NoCS1'?3g(1L9 PhoneZ '1-3L7-gZt:B TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER V (fig�onitoring'Hell DISTANCE TO NEAREST: SEPTIC TANK Na"r� SEWER LINES i10407- DISPOSAL FLD.AJ"V PROP.LINE�h� 0 FOUNDATION Nn'VE AGRICULTURE WELL ALoA—)F- OTHER WELL NRS PITS/SUMPS 00 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r Cl Industrial ❑ Open Bottom ❑ Manteca '1 Dia. of Well Excavation 8 Dia. of Well Casing (l Domestic/Private ❑ Gravel Pack Tracy(LeAaf) Type of Casing_ Z-~ f t"C Specifications I'l Public (1 Other f1 Delta Depth of Grout Seal S �S r � Type of Grout I I Ir i a ionor.� —Approx. Depth I I Eastern Surface Seal Installed by tQ( ��pp�ari�g arr'Work Done U Tyke of Pump H.P. St tq,Work Done , Well Destruction O -Well'Diameter V-'"-L- Sealing Material & Depth Cew a i �S c:, Depth ZS�f Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 1 A Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms / Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well F dation Property Line LEACHING LINE Cl No. & Length of lines I U= Total length/size FILTER BED ❑ Distance to st: ell Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOS NO ❑ 1 here y 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu a If 11 wired inspections. Complete drawing on rover" /Jside. /J/ Signed Title: �v4iw��y Date: 1,9 FOR DEPARTMENT USE ONLY r � Date-LA k;•; f 2 Application Accepted by I Date L res J S Pit or Grout Inspection by//►' ' ' ' !` �Date Final Inspection by ��Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 1 Environmental Health Permit/Services l L _i AN 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13-24(REV.1�n 5) T9. 00 / • OV II-?� �� , 1/1 ✓1 G-- l� EH 14.20