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APPLICATION 'i. 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 FRO -E 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 t Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address , a� Iv ""' D N " City —�IC� b-��' Lot Size/Acreage _ IS119faepAp E �� s Owner's Name Address trltone n VZ Contractor��"� s'4 - Address "�'" s itense No.� Phan 'Z `TYPE Of WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of service Well Cl PUMP INSTALLATION ❑ ° SYSTEM .REPAIR 0 k0fjLT0 T I Monitoring toring Well �y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .29' DISPOSAL FLD��//�� PR P. LINE x7►�( ( + FOUNDATION �t OU AGRICULTURE WELL ..1J� OTHER WELL_%W_0 PITS/SUMPS hi& INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i )<Domestic/Private Cl Gravel Pack ' ❑ Tracy Type of Casing_ Specifications I'I Public -�1 Other f 1 Delta Depth of Grout Seal r' Tye 'Grout I I Irrigation Approx. Depth1 astern Surface Soul Installed by Repair Work Done U Type of Pump H,P. State Work Done _ Well Destruction O Well Diameter _ r Sealing Material,& Depth I�el r�f6 Depth Filler )Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is R` available within 200 feet.) Installation will serve: Residence___. Commercial — Other R' W Number of living units: Number of bedrooms P'AYMEN Character of soil to a depth of 3 feet: ble depth :SEPTIC TANK 0 Type/Mfg Capacity M ��partments PKG. TREATMENT PLT. ❑ MAY -1 iiiolWo Disposal Distance to nearest: Well " Foundation -9AN-eJ0Ag1ARG JtJ�{1T....� PI f 1 iC.HFA�TH.RFRvtcES - LEACHING LINE ❑ No. & Length of lines ENVlR4�11 A�91bh LT DIVISJO 'FILTER BED ❑ Distance to nearest: Well Founcition Property Line .,SEEPAGE PITS ( I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O -+" I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Ieyrs; and rules and regulations of the San Joaquin County Home owner or licensed agent's signature canities the following: "I certify that in the performance of the work for which ehia 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 subcontracting signature certifies the foltowin : "1 comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compsnsa- lion laws of Cailfo The applicant st call for all require pectin Ing on reverse side. /pr1 e---_ f Title: n� _ �p 3 Date: /! lit —w RD PARTMENT USE ONLY Application Accepted by Date Area Pit or rout inspection by Final Inspection by Data Additional Comments: l72 Applicant - Return all, copies o: San Joaquin County Public Health Services � se ^ Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 INF FEEO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMI7'N0, w rn re t . Eli 1'3•24 urty.,,a ar I � �j qS r II 4 t� d03 ). a Eh 1/-2e _