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(�Cf for3o l:vs - =rte G-S ytZ_S APPLICATION 3,v H,tK 7-v777+t-CZ-a lere-A hces S/UAL,) ✓ ��, 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 • ` J i 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 a Section 9-1110.3 and Section;C5.3�a/fnnd})the Rules and Regulations of San Joaquin County Public Health Services. ;tgo Job Addres Lot Size/Acreage - O er's Name __ � �-:--f)T�L.L� -- Address! �� S. r'1!a33`-J• �'/7CC7I� �'1 �n5e f+lo. �1�a7Z hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Ur Out of Service Well , ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ "'€ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES a DISPOSAL FLD_. PROP. LINE Q� s t FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 industrial ❑ Open Bottom ❑ Manteca Dia:of Well Excavation Dia. of Well Casing j fa Domestic/Private f ❑ Gravel Pack I L7 Tracy Type of Casing_ r Specifications ] I'I Public Cl Other n Delta Depth of Grout Seat Type of Grout 11 Irrigation Approx. Depth I I Eastern Surface Seal Installed by I f ' Repair Work Done ❑ 'Type of Pump H.P. State Work Done t� Well Destruction �}Well Diameter `r Sealing Material i'13epth f ,. Depth Filler Material &i Depth IIA TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public Avvel,is s available within 200 feet.) " Installation will serve: Residence_:._Commercial Other d Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f� Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:', Well Foundation Property Lina PAYMENT LEACHING LINE C1 No. & Length of lines r Total length/size KLUENVE ° FILTER BED - (71--Distance to nearest: Weil y Founaation Property Line M1 1 1004 SEEPAGE PITS I I Depth. Sire Number CG�livTY SUMPS- LI -Distance to nearest: Well Foundation Property Line t]1 IanW ALTH 50v1c1t S DISPOSAL PONDS ❑ 4 ' `` EWRON 1 T LA `r,i DI' 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, l 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 parsons subject to workman's compensa- tion laws of California." 1 The app can must II firnuiced inspections. Complete drawing on reverse side. Signed x Title: �� µ Date: f I r FOR DEPARTMENT USE ONLY Application Accepted by 'ys -- - -- - Date Are. Z' Pit or Grout inspection by - -Date ! Final Inspection by Date oa Cf tI JJJ Additional Comments: T 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 FEE AMOUNT DUE' AMOUNT REMITTED K RECEIVED/BY DATE PE�RM�ITVnNO4.INFOH Ht7-24 + *m.IIL CH t I '