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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209) 469-3420 P O BOX 388, STOCKTON, CA 95201-0388 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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address y `i-3 M k (Z t P o Sfi R -D City s�O u(� Lot Size/Acrea.ge Owner's Name (3Sl Ty_ULx_A Ni:; Address P. 0 tBox. -A co I c) Phone q 41 -S'3(, ) DATE PERMIT No. Contractor SPeC gU&A eLPf-- Address � TZS E . M Y1 LIL SI_License No. 5 1226 �� . Phone J TYPE OF WELL/PUMP. DISTANCE TO NEAREST: INTENDED USE L7 Industrial YDomestic/ Private I'1 Public 1 1 Irrigation Repair Work Done U Well Destruction ❑ NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION Cl Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well SEPTIC TANK _4_ SEWER LINES 1\14 DISPOSAL FLD. JiV14 S PROP. LINED0 / FOUNDATION 2-0 " AGRICULTURE WELL �� OTHER WELL 7e_ PITS/SUMPS 1&1A TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r // ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing __4� ❑ Gravel Pack ❑ Tracy Type of Casing _ P ✓C— Specifications— X X OthefO rf�44 r�Delta Depth of Grout Seal G 3' Type of Grout^' 6" ell, pprox. epth fV Eastern Surface Seal Installed by Ste' T�-u -Iy\ �yc ell, Type of Pump N.P. __ State Work Done _ Well Diameter Sealing Material L Depth Depth _ Filler Material i Depth OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) r� Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Other Capacity Distance to nearest: Well Foundation LEACHING LINE ❑ No. b Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Water table depth No. Compartments cj Method of Disposal Property Line l Total length/size_ Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI 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 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 applica u call fpr all r fired i s tions. Complete drawing on rreverse, side. p� Q Signed X Title: / L� Date: FOR DEPARTMENT USE ONLY Application Accepted by%<Date Pit or Grout Inspection by Date Final Inspection by Dau Additional Comments: Applicant - Return all copies to Er' 13.24 (A EV in 5i E!, I'"' San Joaquin County Public Health Service Environmental Health PermiUServices J 445 N. San Joaquin, P.O. Box 388, Stock , CA 95201-0388 331"0) FEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT No. r