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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SER CTSR# • ENVIRONMENTAL HEAL'T'H DIVISION n 445 N SAN JOAQUIN,PHONE(209)469-342 AI V P O BOX 385,STOCKTON, CA 95201-0388 Q P IT iRES 1 YEAR ROM DATE SBU ----.--�_ (Colplete77 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 cAtnpliance with San Joaquin County Development Title Section 9-1110.3 and Section 9-1115-33 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 'r j--gM Ar tt� City 7' Gam� Lot Size/Acreage _zfJer�h+[ Owners Name /t�/{`1 Address �d�/ Az 4 iCY�4 It7G7� _ Phone8'3.5"- 91 OS Contractor Addiess gMa �LveT O!►3 d}CCe� License Na. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR l OTHER Q Marnitoring Well DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E) industrial 0 Open Bottom O Manteca Dia. of Well Excavation_ Oia. of Well Casing r7 Domestic/Private Cl Gravei Pack 0 Trary Type of Casing.-____, �y,�� I'1 Public n Other n 061ta Depth of r1t'Tr�st�a P Grout Seal - 1 ( Irrigation _.Aptxa><. Depth l I Eastern Surface Soul tnstzs(ed bYL+� -- Repair Work Done U Type of Pump H.F. State Work Done 41 N WON Destruction 0 Well Diameter Sealing Material i Depth V{�TY Depth _ �laeertrb,b Depth et rnr rr uJOAQ chl Tu��RVICES TYPE OF SEPTIC WORK; N£W INSTALLATI flEPAIR/ADDITI:?N� STRUCTION! k INC r • is available within 200 feet.] Installation will terve: Residence� Com Gtltar_ Number of living units; .�� Number of bedrooms Character of soil to a depth of 3 feat. 4 T �101'6 SEPTIC TANK ` —' Water table depth ❑ Type/Mig-l'z'l §t4�T l�� L Capaoity l ��d No. Compartments Z PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Weld _ Foundation 3-1 Property Line I a o' LEACHING LINE Cl No. b Length of lines _ To:Oi length/size FILTER 8£D ,6Q Distance to nearest: Well se Founcation 10' Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to neatest: Wail Foundation Property Line r DISPOSAL PONDS _ ❑ I hereby certify that I have prepared thie application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the Son Joaqvin C„ovnty Home owner or licensed agant's signature Certifies the following: "I certify thal in the performance of the work lot which this permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensation taws 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 shell Ompby persons subject to workman's compensa- tion laws of Califorrda." The applicant must 5411 for P41 required inspections. Complete drawing on reverse side_ Signed Title: Date, FOR DEPARTMENT USE ONLY / Application Accented by __ W) Date , /t__ Amina Pit or Grout l;tspsction by Date Final Inspection by r1' ft./tf�LW _ Dario .� Additions! Comments: _6-T,-94 - NtJi��: San � /(J ff sib f1 r,�Ly .�'L� L jLf�0� 1sArplicant - Returo all copies toaqutn County Public Health Services Environmental Health PenniUScrviccs j FEE 445 N.San Joaquin,P,O.Boz 388,Stockton,CA 95201.0388 'L ,kYf" INFO MOUNT ODE AMOUNT EMITTED CK RECEIVED 6Y / ATE PERMIT'NO. EH