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APPLICATION SR je SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC S ENVIRONMENTAL HEALTH DIVISION AiD # 445 N SAN JOAQUIN, PHONE(209)469-3420 P 0 BOX 388, STOCKTON,CA 95201-0388 FkC # I PERMIT EXPIRES 1 YEAR FROM DATE IS81JEDt( # �/ 4 • I (� (Complete in Triplicate) I I . _ 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 r Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations In San Joaquin County Public Health Services. Job Address zS c) p r�J.k t1 iiI& (A f•` VV Lot Size/Acreage V 4 c. Owner's Namey/J� MooY V^ANA h F(R Addresss A� I Phone / / Contractor I CAYV l5 50W5 Address 3re1 1 o N t Vu t 1SD11. _ Cense No. 4 {! 3 Phone %(P(o-q/ 017 TYPE OF WELL/PUMP NEW WELL C - WELL REPLACEMENT Ll DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR C OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE a. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '�yg D Industrial O Open Bottom ElManteca Dia. of Well Excavation �",4Ai`Xfxxx ��pp,iC�sing Cl Domestic/Private D Gravel Pack C Tracy Type of Casing_ Il Public I1 Other fl Delta Depth of Grout Seal ypk"e�o,(Ggouy4(.}� 1 I Wroauon _ Approx. Depth 1 1 Eastern Surface Seal Installed by LT Repair Work Done O Type of Pump H,P. State Work DdSA 4-Ir' 1t`I C`= NTY ,.. Sealing Material i Depth Wall Destruction O Well Diameter I mF.iE#N" Ip QI"R _ Filler Material i Depth PAE"TALHEALTr? R"I..,u• �Jylt TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sower is I l available within 200 feet.) \J Installation will serve: Residence_ Commercial X_ Other Number of living units: _ Number of bedrooms e Character of wA to a depth of 3 teat: _ �M �� Water table depth SEPTIC TANK ❑ T �i; 0 C U No. Compartments Type/Mfg � - $�' Capacity PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. 6 Length of lines Tial length/size O FILTER BED D Distance to nearest: Well Od E Foundation a_ Property Line ,C7 t ` SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation 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 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, 1 shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I cenify 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 Colifor ems) The applicant in cIl�f�orr all require--irAPections. Complete drawing on reverse side. Signed X "' -t • f "'� Title: Ce y Date: su if Vi y CFOR DEPARTMENT USE ONLY Application Accepted by .�,tu DateArea I 7/7 Pit or Grout Inspection by Data ction Final Inspeby Dete�. Additional Comments: ` Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Perms/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 m INFO AMOUNT DUE AMOUNT REMITTED PAS,, RE�CEI(VED BY yam/, DATE `PERMIT NO, . f 13.]a leEv.irmsi fN la 25