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APPLICATION 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 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 De�tle Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Ms �4-48 ( ) o.l=. Wvv,?22W Pm, city LOU 1 Lot Size/Acreage fe•It Ac t Job Address UW4AAr i Owner's Name 1a.E. d3dress •I"O Bax 6 67 !_�► Phon� Contractor, nti+M1 � �_Address 1 r 1 License No,-RC�^ 1%6�hone 22 3(0S6(118 DESTRUCTION ❑ Out of Service Well 0 TYPE 4F WELL/PUMP: NEW WELL ❑ F WELL REPLACEMENTn t w r Monitoring Well s PUMP INSTALLATION ❑ f SYSTEM REPAIR.'L-1— r OTHER ❑ ❑ i DISTANCE,TO NEAREST: SEPTIC TANK. '-S.EWER LINES -, I + DISPOSAL FLD. PROP. � FOUNDATION AGRICULTURE WELL OTHER WELL` f PITSISUMPS INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATtONS� � C7 Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications ['l Public [.1 Other i �n Delta Depth of Grout Seal, Type of Grout I I Irrigation i —Approx. Depth 1 1 Eastern Surface Seat installed by f All Repair Work Done U Type of Pump I H.P. ` State Work Donee_ Well Destruction 0 Well Diameter � - Scaling Material i Depth" �" —f'• Depth_ __Filler Material,& Depth 1 y { TYPEe F SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is T,,g—�- 'M 5 14--;443)4available within 200 feet.) Installation will serve: Residencem _ Comercial_. Other Number of living units: Number of bedrooms Character of soil to's depth of 3 feet: * T Water table depth i SEPTIC TANK D Type/Mf Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance'to nearest: Well Foundation Property Line I s R + LEACHING LINE 0 No. 8 Length of lines ' let length/size FILTER BED n""Distance to nearest. Well ` Foundation ' Line SEEPAGE PITS I I Depth Size Number l -_ _ r SUMPS""" — Ll Distance to'neerest: Wall�-�" Foundation �°�"Property Line + DISPOSAL.PONDS ' O s I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquinA(pRy prd►nag state laws, and rules and regulations of the San Joaquin County _. ,• II�� 1R 11 II�JJJ Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fo�, ;ich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." CoMractl N AQA0WIhL&&#tMqIin9 signature certifies the following: "I certify that in the performance of the work for which this permit,is issued, I shall emplovP cTFa.w?q a j compensa- tion laws of California." Js - r ENVIRONMENTAL, HIEALTM DIVISION The applicant must call for all required inspections. Complete drawing on reverse si a. Signed X Title: Crut/Tii6,r,9"AJ 1CWA0 Date: `r 1-95; r t V. FORDEPARTMENT USE ONLY Application Accepted by _..,_. �'4-� ry DateY Area , Pit or Grout Inspection by y Date Final Inspection by Dated r. 4, .......r - ' r Additional Comments: Applicant,- Return all copies to: San Joaquin County Public Health Services I Environmental Health Pcrmit/Services --- 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388 q FEE AMOUNT DUE' i AMOUNT REMITTEDRECEIVED 9Y DATE PERMIT'NO. Z INFO `E CASH /� /- �y EM 13-21 UtEv.iiN51 3 r�� I / [-� 9 d EH i4-2a �.! l VVV 1 I _