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APPLICATION SAN' JOAQUIN COUNTY PUBLIC HEALTH SERVICES J ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PO BOX 2009, STOCKTON, CA 95201 a PERMIT EXPIRES 1 YEAR FROM DATE - ISSUED (Complete in Triplicate) Application is hereby made to Sap Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County PublicHealthServices. 1 J6b Address �Lf 7 M &DQ/�C:ity 6��_ Lot Size/Acreage R Owner-a Name �/ � ---.-.--,Address Ph�e_ j ¢. i3 t Contractor Addressac'-no N: VY��.�E�I� /License No Phone TYPE OF WELL/PUMP: NEW WELL ❑•— -•-...-..ti...-WELL-REPL-ACEMENT.C7..-.__..,.......DESTRUCTION,,, Out of Service Well j❑ F PUMP INSTALLATION 0 SYSTEM,REPAIR- 0 OTHER:❑ 1 Monitoring welly C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLD. `-PROP. LINE KFUNDATION AGRICULTURE-,WELL _ OTHER WELL` 1 L'*"._, PITS/SUMPS r } _._.;._ .. _-__. r. �.. 3 r # INTENDED USE .'TYPE OF WELL ,rPROBLEM AREA CONSTRUCTION SP�CiFICATIONS ET Industrial O Open Bottom ❑:Manteca Dia. of Well Excavation Dia. of Well Casing �t.14 Domestic/Private 0 Gravel..Pack� n�Tfacy Type of Casing- ''''�13ecifit'ations- I i'l Public la Other xn Delta Depth of Grout Seal 'Type of Grout r r I lIrrigation \i_Approx ,Depth. }I I Eastern Surface Seal Installed by f Repair Work Done 0 Type of Pump - HrP. --- State Wank'Done� ` f Welt Destruction .(]3`.WeIr Diame%er..,. k Sealing Material 8 Depth # E Depth Filler Material &;Depth `- } TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 AEPAIA/ApOfTION I DESTRUCTION I ) {No septic systertltpermit led if ptibGc sewer-is i ! available within 200 feet.) Installatio} WIII aeNe: Residence 06n6ercial_ 6ther Number of living units: Number of be�drooms_ A"b _ Character of soil to a depth of 3 feet: �� _ € Water table depth j SEPTIC TANKfs' S-r❑ TypelMf ;}r>..,.`y' '° "'' 1. g Capacity No"pogtpartments I PKG. TREATMENT PLT. D., a [ Th+Iethod-o Ai osaj' € .., ' �-.... sp Distance to n arest „u. Well Foundation,'' 1 LEACHING LINE w No. & Length of lines T tal length/size .19 FILTER BED: ❑ Distance to nearest: Well 1 "Foundation Property Line a• wq SEEPAGE PITS Depth Size a _ ,umber ► k : SUMPS i Ll Distance to nearest: WaII u n d a t i o n Property LirteOF DISPOSAL PONDS----C``-- -, - >; - . •• 1. i6 �� , . ^ I_ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joagdiii'Vri'ty ordina__e1 state laws, and l w 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 i f shall not artiploy any person in such manner as to become subject to workman's compensation laws of Califorr�." Contractor's hiring or stib-contracting signature . c ' ifies the following: "I certity that in the performance of the Work for whichbthis•p'ermit is issued, 1 shall employ persons subject to workinan:s'compensa- i 4 ti laws of California." s The applicant must call for all req ' ed ' spections. orriplete drawin onreverse"side. T gory a. Slgned Title: fix. F aw spa A12! i FOR DEPARTMENT USE ONLY Application Accepted by Date A�6a or Grout Inapaction:.b.Y, =�'ta -� -® Dat ;Final.inspection�b `'�"'= Y -- "ate- .. Additional Comments: Applicant - Return all copies to: San Joaquin-County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 20091Stkn, CA 95201 ,"_.-�..-." -...:._.s..,•.-.....-...r.- -�--•..•..Mi..�r�...:r r FEE 3 INFO AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a . EH 1344{AEY.in SI O� /.. /6 D ✓ V' o f ' EH i4.3! _ {