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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388, STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 111and Section 9-1115}.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address C135G 5G ' •`-4+ • ,1�huaU `Y City "� n Lot Size/Acreage5220'X I Z7, Owner's Name J( Mrs\ yV�.1 Addressf17355 W Alia W gya �t Phone "fres 76 Contracts 11 ddress-aA41 Jeri 1 License No. !SQL 2k9-&Phond76-7) 745- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "v FOUNDATION ry AGRICULTURE WELL OTHER WELL111_T PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p ❑ Industrial ❑ Open Bottam ❑ Manteca Die. of Well Excavation Dia. of Wall Casing 7v ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing_PVG Specifications -,1 -� I'l Public FI Other XPelra Depth of Grout Seal f Type of Grout Pov4l-AM U3 � 1 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by lush �r�t--7 Il='�I I--113ul CA Repair Work Done U Type of Pump M.P. _ State Work 0 e _ VA Well Destruction ❑ Well Diameter Sealing Material i Depth Depth _ Filler Material i Depth L*-,%? Alen C4yj o n ZE TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted it public sewar is available within 2110 lest.l Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments rL PKG. TREATMENT PLT. ❑ Method of Disposal VE Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to merest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby canify 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 licensed 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 soblect to workmen's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenu tion lava of California." The appil UAP49MSVMII f 11 rs uired i spections. Complete drawing on reverse side. Signed X Title: AA+A46t--T1'— Date: 10"'17', FOR DEPARTMENT USE ONLY Application Accepted by W Date Area Pit or Grout impaction by Date �0 'U Final Inspection by �� Dee/oa 6 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ' Environmental Health Perma/Services 3 5C) 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 FEE INFO AMOUNT DUE AMOUNT REMITTED I CAKSH RECEIVED By DATE PERMIT No. EM taa.IREv.r,xei H H-]a 4 $ � ? � l`f3j —L to/av/9y e�oyy`7 r