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APPLICATION SAN JOAQUIN COUNTY PUBLICID ICES ENVIRONMENTAL HEALTH 445 N SAN JOAQUIN, PHONE 420r 5'OD,1 P O BOX 2009, STOCKTONr 7 P I T IRB YEAR FRi ; (Complete in TriplV# 9A117Applicatioo is hereby ladeto San Joaquin County for a permit to constr -71 application is ride in et�llance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations o n Joaquin County Public Health Services. 4 Ll� � C� Job Address ; � �J _an City ;C 4 Lot Size/Acreage �d a owner's Namei i(— ��d�f. :q Address _ 5�' _ Phone CtM11bCt6r i/M�/\��4�LL Fye t-+�_.�„dt]ress ��_-,� S�QLicense tio. Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT r DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION Q SYSTEM REPAIR C; OTHER 0 Monttoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL yLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7-1 tndusinat O Open Bottom t= Manteca Dia of Well Excavation Dia. of Well Casing C_i Domestic/Private ❑ Gravel Pack ❑ Tf icy Type of Casing_._.._ Specifications i'i Public 17, Other ❑Delte Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done L7 Type of Pump H.P. _ Start Work Done _ Well Destruction' ❑ Well Diameter Sealing Material •. Depth Depth Filler Material i Depth V^J TYPE OF SEPTfC WORK: NEW INSTALLATION REPAIR/ADDITION I r DESTRUCTION i i INo septic system perrtutled if pubkc tewsr is ry avaitable within 200 feet.! installation will serve: Resiidence -Commercial___- Other �— Number of ftvtng units: ____t___ Number of bedrooms Character of soil to a depth of 3 feet: 1,1e t"dt r. Water table depth SEPTIC TANK 911"TypelMfp Capacity ! T n ._ No. CO Wsnments PKG. TREATMENT PLT.❑ r r Method of Disposal Distance to nearest: Well _ n Foundation_1 to) Property Line f&P LEACHING LINE No. b Length of ("ares _-A — O TOtal length/size t FILTER BED ❑ Distance to nearest: Well1i1 r) _ Foundationf 1 ,�i� Property Lints SEEPAGE PITS W Depth -Sure Number_ 3 SUMPS LI Distance to nearest: WON I Foundation _ Propany Line DISPOSAL PONDS ❑ I hereby certify that i have prepared this application and that the work will be done in accordance with San.3oaquin county ordinances,state litxrs,and rules and regulations of the San Joaquin County Morns owner or licensed agent's sipnaturs cortili"the lollowmg. "I centfy that in the performance of the work to;which this permt n issued, I shalt not employ any person in such niannot as to become subject to workmen's compensation taws of California."Contractores haring tx sub-contrectrng signature canities the follamng: "I cenify.hat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawn of California." The applicant must call fm al) required inspections. Comoele drawing on reverse s+de. /a Signed x — — Title: f)lAe Date: FAT FOR DEPARTMENT USE ONLY / Application Accepted by Lk� MA I Dats Pit t inspection by Data Final irtspettion by Date 4pgkq� Ad I Corrxrwtu_ Applicant - Return all copies to: San Joaquin County Public Health Services SPK oDDD 3 `1 Snvirom-ental Health Permit/Services 1 445 N San .Tosgn tn, P O Bo: 2009, 9tkn. CA 95201 ,r FEE AMOUNT DUE AMOUNT REMITTEO RECEIVED By DATE PERMIT NO. i `INF.o\l CASH 3 EN 13N 111FV. �ti fi ala i g� EM war __JJrr�"'