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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 /7 HERMIT EXPIRES 1 YEAR FROM DATE ISSUED(Complete in Triplicate) Applicat on is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application Se made in comp lance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Coanty PuE 8errlcee. /� 1 Job Address -a� �p/ kra-;l IHG d. Ciiy_ _ Lot Size/Acreage S Owner's Name t "t t QJ.t 1�0 AAddd,,,s ' �+�f�L"�t� /' �L Phone Contractor l-.Q'C- ' _Address �3s�-L��ery tN-4c; - (2 4 icense No. Phone a-m TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT C DESTRUCTION C Cut of Service PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER C Monitoring Well a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES T DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom C Manteca Die. of Well Excavation Dia. of Web Casing C Domastiel Private ❑ Gravel Peck C Tracy Type of Casing_., Specifications I"1 Public I:7 Other CT Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done C Type of Pump H.P, Stale Work Done _ Welt Destruction C Well Diameter Sealing Material & Depth Depth Filler Material 4 Depth • TYPE OF SEPTIC WORK: NEW INSTALLATION bf REPAIR/ADDITION 1 I DESTRUCTION 19 INo septic system permitted if public sewer is available within 200 leet.l Installation will verve: Residence '>'-- m Cerrercial— Other Q Number of living units: -j- Number of bedrooms._31 z Character of and to a depth of 3 feet; Water table depth G SEPTIC TANK iiii- Type/Mi Capacity 14711 No. Compartments Pli TREATMENT PLT.0 f Method Of Disposal Distance to nearest; Well. -lei _f'Foundation tP Property Line LEACHING LINE Gf- No. 6 Length of linea _��Z_�zy Total length/size r FILTER BED C Distance to nearest, Weil-ej*A� Foundation _ Properly Line SEEPAGE PITS *C Depth o�S y Site Numbar 3 SUMPS LI Distance to nearest: Well _,A�_ Foundationf G.'4" Property Line_--kvr_ DISPOSAL PONDS D 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 or the San Joaquin County Home owner or licensed ageni signature certifies the following: "i certify that in the performance of the work for which this permit is issued, I thaw not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature cartifiss the following: "I certify that in the performance of the work for which this permit is issued, I shall empty persons subject to workman's compensa tion Iowa of California." The applicant must I for all req ad psttioM. Complete drawing on reverse side. v- Q Signed X��,o+'t Title O ro 0 $1� Dale: 7- o ` /3 R DEPARTMENT USE ONLY Tib APWication Accepted by Date�� Arae d2 1 2- I r,V /'71S �� It) lMepectbn by ., ,=. Date ind Inspection by 3 • Adc hional Comment: v Applicant - Return all copies to; San Joaquin County Public Health Services rJ 900tDO if Environmental Health Permit/Services 445 N Sao Joaquin, P 0 Box 2009, Stkn, GA 9 __. NPO AMOUNT OLE AMOUNT REMITTED CASH PELEryED BY DATE PERMIT NO. EH t}3.1aEy ,,,,t ' fie 16]D