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'p APPLICATION `rr ft SAN JOAQUIN COUNTY PUBLIC HEALTH SERV_ICES J ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-1420 y6 S-3tilo P O BOX 388, STOCKTON,CA 95201-0388 PERMIT E%pTRE A FROM DAT ISSUED ((Lomplete 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. Minor scald. Job Address 22180 E. Milton Road Cny IailldEfl Lot SSte/Acreage 3-211,0. } lrihw Owner's Name Robert Bell Address 221.80 E MiltM Road Phone 887-3630 Contractor Owner/Builder Address 22180 E Milt0E1 Road License No. Phone_9U—,3&30 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 _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications I-i Public 1-1 Other n Della Depth of Grout Seal Type of Grout I I brlgallon _Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth _ Filler Material i Depth .TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION 1 I DESTRUCTION 11 (No septic system permitted if public wwor is (SOIL SUITABILITY S IDY FOR S=C SYSTEMS DESIGN.) available within 200 feet.) Installation will serest Residence_ Commercial_ Other PERK rl. .r C�II,Y AT THIS TIME.�'3 Number of living units: _ Number of bedrooms 01 character of soB to a depth of 3 feet: MS — 94 — Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:) Well Foundall Property Line LEACHING LINE ❑ No. g Length of lineij Total length/size FILTER BED ❑ Distance to nearest: Well Founaabon Property Linr,e7r%=1l1E 0 SEEPAGE PITS 11 Depth 1 Site Number - SUMPS LI Distance to nearest I Well Foundation— Pro r 1 (:OUIVTY jpertv�i4lu DISPODAL PONDS ❑ p USL; r,,i Al I I hereby cenlfy, that I have prepared this applicator and that the work will ba, done in accordance with ${'6"466i4M�i"c6oAty�0"'dmances, state laws, and rules and regulations of the San Joaquin County , Home owner or licensed agent's signature canities the following: "I certify that to the performance of the work for which this permit is issued, I 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 certify that in the performapee of the work for which this permit is issued. 1 shall employ persons subject to workmen's compensa lion laws of California." The applicant must call for MI required Inspections. Complete drawing on reverse side. r Signed 1 Title: a Ne•rM�•✓f/. Data: �� •Zr2y r L. `"•.,.,,, FOR DEPARTMENT USE ONLY Application Accepted by Dale Ans. Accepted Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 1AMOUNT DUE AMOUNT N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 FEE 1 a,7 2;7-* INFO NT REMITTED Cif' RECEIVED BY DATE PERMI7'NO, . En p9.IAEv ileal y !1 -