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A APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SEV%,%�- ENVIRONMENTAL HEALTH DIVIS ON # 445 N SAN JOAQUIN,PHONE(209)46 -342 P O BOX 388,STOCKTON,CA 95201 03$8,0 # ; PERMIT EXPIRES 1 YEAR FROI1 D TE .S►SSUED iYi/a y3 (Complete in Triplica e7 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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of Sa/n�Joaquin County Public Health Servli�ces. Lot Size/Acreage / C_ JobAddress D • City �j ��) 4-`3q t Owner's Name �`qJ^ C9Q41,:4 Address ~`C- - Phone Contractor Q�JI(/rE Address ��"�"t-- License No. Phone of TYPE OF WELWPUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out Mo nitoring Well Service Well ❑ I PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER Cl Mo DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINES FOUNDATION AGRICULTURE WELL OTHER WELL PiAMMI.T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R r—CIVEI - I nJ C7 industrial © Open Bottom ❑ Manteca Dia, of Well Excavation Dia.p1jl►C [I Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Speci stag `s r Depth of Grout Seale `1r Ni ��' I'l Public Cl Other �1 Delta P I I Irrigation Approx. Depth t I Eastern Surface Setif Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Staling Material i Depth Depthr Filler Material i Depth TYPE OF SEPTIC WORK: NEW IN I 1 REPAIRIADDITION DESTRUCTION INo septic system permitted if public sower is vailable within 200 feet.l Installation will serve: Residence Commercial^ Other Number of hying units: �_Number of bedrooms af Character of soil to a depth of 3 feet: Water table depth OD . SEPTIC TANK (� Type lMfg Capacity aQ 6 No. Compartments - PKG. TREATMENT PLT. ❑ �r�� ff 14.10 Method of Disposal Distance to nearest: Well �1-� foundation Property Lina $d f LEACHING LINE In No. A Length of lines Tgtal length/si:e 1520 �S/� ��, FILTER BED 1 Distance to nearest: Well V Found8 ation 3Property Line 152 f SEEPAGE PITS 04 Depth _ -� - Sire � Number f' SUMPS �Q Distance to nearest: Well Foundation ✓ � Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and _ rules and regulations of the San Joaquin County Home owner or licensed agent's signature candies 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 I 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 must call for all required in ctions. Complete drawing on reverse side. ` Title: w Date: Signed -�� FOR DEPARTMENT USE ONLY F Application Accepted by Date Area /z j a Grout inspection by Dat �"� Fjinel Inspection by ) to Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services I 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 ' •FEE AMOUNT DUE AMOUNT REMITTED ASHRECEIVED BY DATE PERMIT•NO. VS..' INF�j . 401 y - -'IKI* EM r]•24 INEE�+.+i R Sf a I EM t4•Ie . . _L114-11 __ _ I