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�..►r APPLICATION Z� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVuD 4,_ ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-342lss' UEDft FACP 0 BOX 388,STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE .. (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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. ) �c Job Address �`� -� *� .y� f/1V� City _ Lot Size/Acreage r Owner's �MJ� Address �✓f ��NJ�� ./ �/Y Phone 1 i 0!y Lf�I Contract < S Addres L, r License N15Z:�� Phonee - —Z!!-C _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION ❑ Out of Service Weil ❑ PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation AA_pja„pl yl(e1LCasing Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �fe. in lions, la, 1'I Public 17 Other fT Delta Depth of Grout Seal � rrppt 'tam I I Inigatton _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. __ State Work DAH L Well Destruction O Well Diameter Sealing Material a Depth CAN flh, v JS I I'CS Depth_ Filler Material i Depth PUBI IG No r+_I I. ,'=--, cSIOhI TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION I I DESTRUCTION I I trc system permitted if public sewer is available within 200 feet.] r Installation will sena: Residence, Commercial_ Other Number of living units: i�i C_Number of beA_roo//ns Character of soil to a depth of 3 feet C_ Water (able depth SEPTIC TANK Type/MfgNis CompartmentsNo. ComparnCompartments Method of Disposal PKG. TREATMENT PLL ❑ r < ' al f Distance to nearest: Well AT'2y1rZ Foundation `'-til, Property Lina v �\1� +� LEACHING LINE No. b Length of lines -� -- S '=� Total length/size ``� FILTER BED ❑ Distance to nearest: Well r�� -f-Foundation Property Line �'�• �� r SEEPAGE PITS 0, Depth Size .c��3•r Number SUMPS LI Distance to nearest: Wall : Foundation/I!Ef Property Line DISPOSAL PONDS ❑ 1 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 rues and regulations of the San Joaquin County Home owner or licensed agent's signature candies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not 'employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I cenity 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 California." The applicant st ca/ll for all requ a inspect bns. Co plate drawing on reverse side. U Ile, Signed X i / -c c'2. J/L. Title: '�-�T-!�� Date: FOR DEPARTMENT USE ONLY Application Accepted by - `'��[l ]"[" --� Date Z Area IN. Pit or Grout Inspection by fVl Date / Final Inspection by at, Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services r 2 1\ 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388 FEENFO AMOUNT'�O1UE AMOUNT REMITTED CSM AL 6' GATE yPERMIT'NO. Vrz.z.urv.ir.v /JS � ' LI- � I� �� '7(L `�C,� O� JV � i zH azs 1 UV" V a