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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIQF# ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469- 20 # _ P 0 BOX 388, STOCKTON,CA 95201-0 88 a2 PFEMIT EXPIRES 1 YEAR F OY D (Complete in Triplicate) Application is hereby nude for San Joaquin County for a permit to construct and/or install the work heroin described.This application is made in compliance with San Joaquin County Development Title Section 9-111/03 and`S1ection 9.11-115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 30 035 h1G<-A1"`)'�'1VY ,J(�t\hf Gty��+L Y Lot Si xe/Acreage �J� f ti1a{cr-:a1 Rccn✓«r Owner's Narne SO�scl �A�Cci �C�Stn$s.r- Address Coo E_ „�'C+ S ei - Phone 105 - 1215 1 CAI Il-,cense c Conlucin f` C.04G04 ; CO.. Address �� P''P_r 1/v � Lr rt•h -cense No. �O(o193 Phone 2 4-�f Z(o TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT CJ DESTRUCTION 0 Out of Service Veil 0 PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER 0 Monitoring Won ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y7 0 Industrial Q Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Caging UYi`N f] Domestic/Private 0 Gravel Pack G Tracy Type of Casing-�.��a`pecifiattore Q I'1 Public CI Other f" Delta Depth of Grout Sees T _ 6pe of Gtoul I I Irmpatmn _Appok. Depth t I Eastern Surface Seal Installed by 1..3i Repair Work Dane ❑ Type of Pump M.P. _ Stet` 'k ' Well Destruction 0 Well Diameter Sealing Material A Depth JL' Depth_ riper Material a Depth j\ti TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTIEyf�(` ti em permitted it public sewers I ridable within 200 fert.1 C, installation will serve: Residence _ Commercial X Other Number of living unhs:_ Number of bedrooms u Charectw of ads too depthof 3 IML: C Ve 1,Y lOc:tl'l Water table depth �s SEPTIC TANK ei!y / 500 �j I No. Comparrmtenta Z PKG. TREATMENT PLT,0 I Mettaid of Digporjet At Distance to nearest: WIN 2¢U F0 notation U Property Line 1(00 (ALLU -Proper d) LEACHING LINE 0 No. a Length of Buys _ S J 8 5 Total length/size (} TA , FILTER BED 0 Distance to meaner: Well Foundation / SS Property Line .3.55 n SEEPAGE PITS I I Depth Sire Number 1 v SUMPS LI Distance to m rest: Well Foundation Property Una �t DISPOSAL PONDS 0 I� I hereby comity that I have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinances, flat*Laws, and C rules and regulations of the San Joequin County Horns chimer or licensed agent's signature terrifies the following: "I minify that in the perlormance of the work for which this permit is issued, 1 shall rot ampioy any pawn in such manner as to become subject to workman's compensation lows of Criifornis."Contractor's hiring or auDcdntracling signature certifies the following: "I artily(let in IM performance of the work for which this permit�ajawed, I shall e�m`ploy�peraldne subject to workman's c nal- n tion sen of California." It-22-q 'iR- ku9 a,.azrµc (/NLa 's SuA. e5 (,Y The applicant must call to At required inspettipne. Complete dowing on reverse side. Signed X Title: ,(� r� FOR DEPARTMENT USE ONLY *, Q OO Applkat Accepted by Data a— alAna l h 4A0, Gr*nT'Inapeqtlon bylogs-114� Date, � Final Inspection by Dna �- 9LT q AddMidel Comrten4: , I ,n, /' Applicant ;Return all copies to: San Joaquin County 19blic Health&rvices Environmental Health PermiLIServices _Jon.joaquin.P.O.B x 38 lockton,CAy3 1A3S8 INF AMOUNT DUE AMOUNT REMITTED Cx RECEIVED lY DATE AMIT'NO. EN rL>•IaEv.lie>i ' 001 114, DlC 'r12- I6