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APPLICATION S JOAQUIN COUNTY PUBLIC HEALTH SI1'ICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE f Qa P 0 BOX 388,STOCKTON,CA 95202-0388 it PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) . { Application is hereby made to San Joaquin County for a permit to construct andfor install the work herein descn'lhed.This application is made in compliance with San Joaquin County Development Title Section 9-1110.3 and Section 9-11153 and the Rules and Regulations of San"Joaquin County Public Health Services. Jab Address 2_O0 AJ0r_rA eek rt City Lady Lot Size/Acreage 5ex�t 7"00 �2. 4 Owner's Name Incegv.`�! $ doe-rvr dress 775'7 S. A rpa tu." St to Phone g�2�-� 6 7-5 � i Contractor Address !^�-i LicenIse No. �- 4 TYPE OF WELL/PUMP: NEW WELL C3WELL REPLACEMENT Cl ` OESTRUCTION ❑ Out of Service Veil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1 I OTHER ❑ Monitoring Wel] DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES � DISPOSAL FLO. PROP. LINE-7-"'50 i FOUNDATION J AGRICULTURE WELL }��OTHER WELL PITS/SUMPS N4 .3 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing I-) Domestic/Private (Gravel Pack+ ❑ Tracy Type of Casing_P t/(,�r_ Specifications 1'1 Public 0 Other fl Delta Depth of Grout Seat !, /4` Type of Grout l'C�411177 t/ efT I I Irrigation ffApprox. Depth I I Eastern Surface Sabi Installed)by i'e fi!`�"C 41 X U I Re air Work Doneg U Type o! Pump H.P. 11 State Work Done _ i. P IJ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth _ Filler Material i Depth I :i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I Ma septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms ?� Character of sail to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity I� No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation it Property Line LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED 0 Distance to nearest: Weil Foundation 11 Property Line 0 SEEPAGE PITS I I Depth Sue I Number', SUMPS Ll Distance to nearest: Well Foundation I; Property Lirm DISPOSAL PONDS ❑ 11 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 cou itr 1 Home owner or licensed agent's signature certifies the following: "t certify that in the performance of:jthe work for which this permit is issued, t shalt not employ any person in such manner as to become subject to workman's compensation taws ofCalifornia." Contractor's hiring or sub-contracting signature eartifies 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 taws of California." The applicant mu till far all quiradin ns. Complete drawing on reverse side. A� I } Signed X `�� — Title: �C /t`1��aalte r Date: II . 4 FOR DEPARTIWENT USE ONLY' Application Accepted by Date Area [ I Pi i i inspection b Date Pit or Grout Inspection by Date F n: 1 apectto y Additional Comments: Pct Lscue.,4 4vv_c e. 1 1-QJ'xzmv� Applicant - Return all copies to: San Joaquin County Public Health Services j Environmental Health Pcrmit/Scrvices 445 N.San Joaquin.P.O.Boz 398,Stockton,CA 95201•(}388 li F4 FEE AMOUNT DUE AMOUNT REMITTED CK liRECEIVED BY DATE PERMITNO. M INFO CAS44 EH 11.24(ACV.I1"5) �`] u. 6-7 a 1 i