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APPLICATION SAN*AQUIN COUNTY PUBLIC HEALTH1ERVICES 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 (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 in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1�alty cr"c Lot Size/Acreage 13.9'/AGf Cs e' �I �P� a �� z j v� �ry{1_ p Owne�r�s�ma .S�l <- Address 080 - rr-eru�.. l(k e D 111. �tr•r<K, 1,l phone Contractor ^'3Q11_ _ 1 DY'� �dress,la.?-qtFr-&C ,_ 4I(_ !_icense No. S M-49al-V lone� TYPE OF WELL/PUMP: NEW WELL ❑ WELL R)EPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ]Ff- Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �n „ F] Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of WeWCasing C.I Domasti /Private ❑ Gravel I-C Tracy Type of Casing_ Specifications I"I Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout trig ion _App, epthI I Eastern Surface Seal Installed by Repai Work Done IJ Typs of ump H.P. __ State Work Done _ Wel Destruction ❑ Well D' meter Sealing Material i Depth !otu.wt Dept Filler Material i Depth — C1 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted d public "war is available 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued. 1 shall employ persons subject to workman's compensa- tion laws of California." The applicast must c II for all required inspections. Complete drawing on reverse side. Signed X • LS/U A-5<a Title: / g2:�(oa s4— Date: Z& Q c� C / FOR DEPARTMENT USE ONLY Q p�GG Application Accepted by Ic(✓ Date ( � q Arai Pit or Grout Inspection by Date �4 / Final Inspection by Dazs 5 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services Gr l 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By INFO CASH ' DATE �P0ER3M�IT�JN]O. 1f y Page 131 EM 1114[REV.1/%!I Hu.7a