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APPLICATION sce .F•C /n ®r G(Jefr,� - f^QC,�[Lr.-eco C20 `SAN JOAQUIN COUNTY PUBLIC HEALTI- Skl I S �-i eA dr cq*d v.�-t Lz or , &O , ENVIRONMENTAL HEALTH DIV) IOC! V e,•,, ,y ��,n,>./�� 445 N SAN JOAQUIN, PHONE(209)4 9 {� P O BOX 388, STOCKTON, CA 95201 00C it PERMIT E$P I RES 1 YEAR FROM D �kJ (Complete in Triplica ` Application is herebymade to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address L ' �' 7� City Lot Size/Acreage } 7 / Owner's Name Address _ Phone — i it .� r � � � r Contractor - L ass ' ' L i -$e No, Y ^ Phonex-2/0 i TYPE OF WELL! M NEW WELL ❑ WELL REPLACEMENT DESTRUCTION O Out of Service Well Cl # PUMP INSTALLATION G SYSTEM REPAIR C] OTHER ❑ Monitoring well C7 f DISTANCE TO NEAREST: SEPTIC TANK SEWER ONES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom ❑ Manteca Die. of Well Excavation Dia, of Well Casing. f.I Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 1.1 Other (1 Delta Depth of Grout Seal Type of Grout t } 11 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done (3 Type of Pump H.P. State Work Done 4� Well Destruction 0 Well Diameter Sealing Material i Depth r { Depth T Filler Material i Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION l .'REPAIR/ADDITION I I DESTRUCTION I I tNo seplic system permitted it public sower is available within 200 feet.) h �. Installation will serve: Residence _L Commercial _ Other i Number of living units: Number of bedrooms _ { v _ Character of soil to a dap h of 3 feet: Water table depth SEPTIC TANK # Type/Mfg ry. L- Capacity 2-0Gu No. Compartments PKG. TREATMENT PLT. Ll Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING ),INE Cl No. d Length of lines _ -~' � Total length/size ifi FILTER BED ❑ Distance to nearest: Well 11 F7 C- ounoation Property Line SEEPAGE PITS 11 Depth Size " Number r�1 SUMPS LI Distance to nearest: Well 7 _��nurtdalian � Property Line �' f DISPOSAL PONDS ❑ 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 County Home owner or licensee 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California.!, The applicant sl�1111101�rqupr�Insl*�CllonCo plate drawing on reverse side. 7 Signed t Title: Dale: /1 FOR DEPARTMENT USE ONLY Application Accepted by 1f41 LQL'13 Date -_�arq C%LI A r a a Pit or Grout Inspection by Date l t rxs: +I Inspection by _ % ' Date Additional Comments: /' or Ce "I a', r tr l Ap l icrint - Return all copies to: San Joaquin County Public Health St-Mrrs SO a4A (-p V "t i r Environmental Health Permit/Services Q C� �Sr ff 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0368FEE - r� INFO AMOUNT DUE AMOUNT REMITTED tc H RE EI EA BY PATE PERMIT NO. FH 14.76 IREV0, r�51 ; 3� /I L.."'ni �[J 71-' -` 2-4 d j�5-/ a