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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 . 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services . Job Address 7906 Al, ELborcAbO STrzEE 1 City 5T0c4< T0rJ Lot Size/Acreage O. S Owneis Name AfLCO PRohuc4S Go , Address P. O . (ivy Salt SAN ryenEu SA 9Ys96 Phone 415-/S71 - 2434 Contractor WAYaE bRILu.J6 Co . Address 26. t&jlC TZL u..lcnw CA 9X '18 License No. 37( 314T Phone 91L 64S - TOYS TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER R Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE /Or FOUNDATION Is AGRICULTURE WELL OTHER WELL IO' PITS / SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom C] Manteca Dia. of Well Excavation B " Dia. of Well Casing ❑ Oemestic/ Private ❑�r Gravel Pack ❑ Tracy Type of Casing _ Specifications I"1 Public Y-'t Other - Votttel6 Delta Depth of Grout Seat ISr Type of Grout CEftEUT I I Irrigation 113Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H . P. Sate Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR /ADDITION I I DESTRUCTION I I ( No septic system permitted if public sewer is available within 200 feet. l Installation will serve: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of wil to a depth of 3 feet: Water table depth SEPTIC TANK . O Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal rsA T Distance to nearest: Well Foundation Property Line --404MENT EN ! LEACHING LINE ❑ No. Al Length of lines ToR;w FILTER BED ❑ Distance to nearest: Well Foundation R 7 8 ',993 SEEPAGE PITS 11 Depth Size Nce wkl F • rSUMPS lY:RVICES 0 Distance to nearest: Well Foundation NTAl- H"6TH piVIS�ION DISPOSAL PONOS ❑ I hereby certify that I have prepared this application rid that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Homs owner or licensed agent's signature certifies the following: all 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 workmen n compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fogowing: 441 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californla," The applicant must call for all required inspection, Complete drawing on reverse side. Signed 7L . 1 ✓ 4/ /6,aat� Title: /°/20leZ7F 6C'ZLae IS-7 Date: FOR DEPARTMENT USE ONLY Application Accepted by 'C Dale —�� ( Area Pit or Grout Inspection by Date / Final !^spartion by '1S Date Additional Comments: �76 /5� / Applicant - Return all copies to : San Joaquin Co my Public Health Services 29 �� Environmental Health Permit/Services G / 445 N San Joaquin , P O Box 2009 , Stkn , CA 95201 // F!R E AMOVM REMITTED CKASH flECEIVEO SY DATE PERMR' NO. 14-M . xa, �9 i�w I ��3 _„ te.zs