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),9h3 APPLICATION -0 z C7tuwnr SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Nv�k 04 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ' "� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED g (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 OrdinanceNo. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City S� l7ri4ZS/Oib6t Size/Acreage XOwner's Name /1 L A-P^A •&df It A Address 3 /9 Phone yy` �� `�6gntractor 4✓%L 4 iA.L'7 i,I• A'.49RAdress 3 S`fo -_ j9*lr L/`-'7!!!el.icense No. Phone U'S-kDc TYPE OF WELL/PUMP: NEW WELL ❑� WELL REPLACEMENT Cl DESTRUCTION C] Out of Service Well ❑ PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE OSAL FLO. PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CO UC SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca is, of Well Excavation _ Dia. of Well Casing, Cl Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing_ Specifications I'I Public L1 Other Delta Depth of Grout Seal Type of Grout G I I Irrigation App- epth l I Eastern Surface Sea$ installed by ` Repair Work Done L3 Type of Pump H.P. ____ State Work Done , } Wall Destruction ❑ Well Diameter Sealing Material & Depth r Depth Filler Material & Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I>CfNo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity L No. Compartments PKG. TREATMENT PLT. D k # Method of Disposal Distanci to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina 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 subcontracting 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 applicant must call for all required inspections. Complete drawing on reverse side. � r _ - Signed X/Yl /1'17 •/GC.e� Title: b w/�r !Z _ Date:J `/7 — r/3 /� F DEPARTMENT USE ONLY rt Application Accepted by (rAJT.CM �I� ' Date Area 6 V {J Pit or Grout Inspection by Date .Final Inspection by Data $ 1 3 Additional Comments: . Applicant - Return all copies to. San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE INFO yAMOUNT DILE AMOUNT REMITTED CK RE EIVED BY DATE PEAMIT'NO.. • ENl3.241REV,r/n51 EH 14-70