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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SE vat 55' , ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209) 469-34JAID# P 0 BOX 388, STOCKTON, CA 95201-0383 rtu PERMIT EXPIRES 1 YEAR FROM DATE (Complete in Triplicate)1INV# 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. ;".6 31 Tal C it S-17'Ck A'44--- Lot Size/Acreage 1+ Owner's Name SI" 61 i al e S, Address ‘B CY. 5--3e)3 &tux in,— q.5-.208 Phone 2-eci -61 4 Y-‘26S/ Contractor V C kiu" / I' A isi4 C Address &K.'SI ?IC %h-Ctt- I/ 5;'/ License No. C., .575' 7$." Phone 4ii -4.,7 TYPE OF WELL/PUMP: JEV*71—WELL 'Igt, WELL REPLACEMENT E1 DESTRUCTION D Out of Service Well 0 X PUMP INSTALLATION E SYSTEM REPAIR D OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE /C) , FOUNDATION i‘C'' AGRICULTURE WELL 1re' OTHER WELL d ie) ' PITS/SUMPS ..a' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation e - Dia. of Well Casing 2 f.1 Domestic/Private )1i4 Gravel Pack 0 Tracy Type of Casing tate- 5 d.i.cl •C) Specifications '37; I'l Public n Other 1-1 Delta Depth of Grout Seal gel Type of Grout .t I I Irrigation j0s2_ Approx. Depth kj Eastern Surface Seal Installed by Git•-/5-ir< twit, Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter 2:, Sealing Material & Depth bre.iftArik .?..7 Depth /cfC Filler Material & Depth Me iticre 1 TYPE OF SEPTIC WORK NEW INSTALLATION 1 1 REPAIR/ADDITION 11 DESTRUCTION 1 1 (No septic system permitted if public WM!! is available within 200 feet.) Installation will serve: Residence Commercial Other _ . I Number of living units. Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line r 1 , LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Founaation Property Line ':. .. SEEPAGE PITS 1 I Depth Size Number % SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 applicantust ',ill for all uired inspections. Complete drawing on reverse si e. Signed X ' ( 44A""k-- Title: eirt1•77' triFiltel (illii''‘•/114444e : 8151‘) OR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by Date Final Inspection by Additional Comments• San Joaquin County Public Health Services Environmental Health Permit/Services 445 N. San Joaquin, P.O. Box 388, Stockton, CA 95201-0388 FEE INFO h)id' AMOUNT DUE AMOUNT REMITTED CK i CASH CASH RECEIVED BY v a o 'r---__ _, 5 '9 rt ei /A A19,1_ 2V/A/' 7Y733N Date Applicant - Return all copies to: E11 1124 (REV. I/ 451 EH 14.2e -1Zo 0 PHS 133 (2)94)