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APPLICATION —!� SR# .� -1--�-j� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC S ENVIRONMENTAL HEALTH DIVISION AID # 445 N SAN JOAQUIN,PHONE(209)469-3420 FAC # P O BOX 388,STOCKTON, CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE I S U 11 # V l (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 DevelopmentC) ' Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address zg ��'` 1�� t City�A VO Lot Size/Acreage Owner's Name hOOY1nAAN Address Phone Contractor pUVY igen 50 WS Address 1 1 I V r wt I5OKU cense No. 451y3ly 3 Phone r` (o `b0F7 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well U 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 0 Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation PAVW,"W: sing Cl Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ ,,x,066 �'t ('I Public (I Other n Delta Depth of Grout Seal 21_Type►qj,�G� I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by T r Repair Work Done U Type of Pump H.P. _- State Work Dowty 1IN N Cili.lNTY Sealing Material i Depth n ref P.1 TH 5 - Well Destruction O Well Diameter rn� OI�I�SI�N ( � Depth _ Filler Material i Depth €r�nanniMFNTHI HEALTH . /v�ll TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION V DESTRUCTION I I (No septic system permitted if public sewer is I y available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Z D / Character of soil to a depth of 3 feet: _ ,�}.�ti Water table depth SEPTIC TANK O Type/Mfg E X It'll l n 4 Capacity Zf7 O V No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. b Length of lines T51al length/size O FILTER BED ❑ Distance to nearest: Well 100 i Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby 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 periormance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen'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 Cali' or The applicant mu c for all requir pections. Complete drawing on reverse side. Signed X _tom Title: ,E o Dater FOR DEPARTMENT USE ONLY R Application Accepted by I Daterea v Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 a FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. INFO • a-CIEN 1J-2t(REV, A0?4, — a