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APPLICATION SAN 9AQUIN COUNTY PUBLIC HEALTH •,;RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _ r r _ 'I �f Job Address 5 I ( City ,�yradi Lot Size/Acreage 1 3 •cN A e.f�e Owner's Nam' til r I Address �� Phone c 2 s- ` /, + 6C vt !'a ae"I OA q990 Contractor kt"fE�dl V"I �flli vLi YI]1 IG ddress 3106 kRrnwr- E �f Sfi . 1 License No(/S7d 4tf(d Phone - '- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well ❑ So', 1 Oc1 ,0,' ,'§7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ IN TENDE USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1•S i r l c Dia. of Well Caning t Cl Domesti /Private ❑ Gravel Pack Tracy Type of Casing_zQZA Specifications _ I') Public (-I Other Il Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 11 Eastern Surface Saul Installed by Repair Work Done ❑ Type of Pump H.P. Slate Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth , 11 Depth Tiller-Material i Depth il)I'fk L�yA yC1(/I't/{�i�4111 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system Permitted if public sewer n available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of will to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Lina SEEPAGE PITS i I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby sanity 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 candies 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 runner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting signature certifies the following: "I candy,that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. tion jaws o1 California." The applicant must call for all required ins ction{e,. Complete draw ng on/yJeverse side. �1(y Signed /� ia, ( x[11 Title: 16�GL)QI )� �_ o`d icS Date: FOR DEPARTMENT USE ONLY Application Accepted by ` ` Date 3 �3 � Area Pit or Grout Inspection by Date 7 t� Final Inspection by l Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH flECEIVED BV DATE PERMIT NO. L c 31 S �n Page I3I3 EH ;3 24.mlaEv...xs. "�� / TS GCL$SII