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APPLICATION SAN JOAQUIN COUNTY PUBLIC SIR RVICES qA ENVIRONMENTAL HEAT 445 N SAX JOAQUIN, PHONE ( 0 3420 P 0 BOX 2009, STOCKTON, PERMIT FXPIRES I YEAR FROM DM LS311 a i (Complete in Tripli Application is hereby made to San Joaquin County for a permit to construct and/or Install the work hereir. described. This application is made in caa�liance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address '44 �_-- CIIV �/t ' `- Lot Size/Acreage Q Owner's Name Address _ J�7 - _ Phone Contractor Addresf (_�j7 /L� -�L�cerise No, � � Phone/ TYPE OF WELL/PUMP NEW WELL rJ WELL REPLACEMENT ❑ DESTP.UCTION ❑ Out of Service Well ❑ PUMP INSTALLATION G SYSTEM REPAIR(/ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES J DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS P, Industrial ❑ Open Bottom C, Manteca Dfa of Well Excjvat)on Dis. of Well Casing C1 Domestic/Private Cl Gravel Pack O Tracy Type of Casing Specifications I'I Public 1-1 Other 171 0e11s Depth of Grout Seai Type of Grout I I Irrigation —Approx. Depth I I Easlem Surface Seat installed by Repair Work Done U Type of Pump H,P. State >Vcirk Done , Weil Destruction ❑ Weill Diameter Sealing VAterial _'" Depth Filler Material 16 TYPE OF SEPTIC WORK. NEW INSTALLATION I i REPAIR/ADDITION DMAWCiIQb1 k3411fo septic system parmilled if public sewer is yy ff��ii'`111lCC JJ vv availabfs within 200 leet.1 Installation will serve: Residence*'!`._. Commercial Other —_ SAN JOAQUIN Number of living unite:I Number oof't",��rooms PUBLIC HEALTH -EI- Character of soli to a depth of 3 feet_ �"�ti EN'MONMENTAL HEAL(r; Water tank depth v SEPTIC TANK O Type/Mfg Capacity No. Compartrnanis PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest, Well Foundation T Property Line LEACHING LINE Jar No. & Length of lines _ 6ne Total length/size FILTER BED ❑ Distance to nearest Well ± Foundation 111_ Property Line ] -T SEEPAGE PITS If Depth 7-r Size_ ` �Nu�mber SUMPS Lf Distance to nearest: --we( �t7 Foundation 6ea Property tine ZA�) —� DISPOSAL PONDS ❑ 1 hereby certify that t have prepared This application and chat the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regWauons of the San Joaquin county Hoene owner or licensed agent's signature candies the foNowing. "I certify Ihat In the performance of the work for which this perrtrt 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 t!iat in the performance of the work for which this permit is issued, I%half employ persons subject to workmen's compensa- tion laws of California." The applicant must all for W r s.:Co�mpl 'drawing on reverseside Sig Title: i 1- r) Date: J FOR DEPARTMENT USE ONLY Application Accr,3ted by 14 Date / Area �k (}tout Inspectbn by , Data #;i V Final inspection by Da:e 1 Additions! Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �r'✓p� f ��` Environmental Health Permit/Betvlcea �1 445 N San Joaquin, O Box 2009, Stkn, CA 95201 !i `I IN AMOUNT DUE AMOU REMITTED , Cx RECEIVED BY 0 E PERMIT NO. EH 13.14f11EV.I/-6f IL EN 1431