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APPLICATION CD ate. j SAN JOAQUIN COUNTY PUBLIC HEALTH SE V JR uu +� ENVIRONMENTAL HEALTH DIVISTON �� tt - 445 N SAN JOAQUIN,PHONE(209)469-34 0 # P O BOX 388,STOCKTON,CA 95201.038r-AC l of--------- C)7 l �/j PERMIT EXPIRES 1 YEAR FROM DATE �ISSUE ///i� ^ q� �- J (Complete in Triplicate) L— 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 81115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Aon,ess �' � 'J� Z`/`�. CA_4-1 '��` /��// yCC.ty ?'1a� Wt SSze/Acreage tel./j. ��Cift Ovmar's Nam)e.ci��.A`/d-L'11i�!l Atltlrasz Phone " � Conhactor✓i!/�/moi!t e .�`��/ Address l Z 7� CLicense No C E Phone TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT n DESTRUCTION C Out of Service Well C PUMP INSTALLATION G SYSTEM REPAIR CD OTHER C Monitoring Well C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA FIM PROP. LINE FOUNDATION AGRICULTURE WELL OTH� ,�j' � PITS/SUMPS .esT or;IJ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECII" C Industrial C Open Bottom C Manteca Die. of Well ExcavaQ�yv, A��T��V�7 Dia. of Wall Casing CI Domenic/Private C Gravel Peck C Tracy Type of Casma pull I nlgN ficaulons I'I Public ❑ Other fl Delta Depth of GmuCi Q Vq�ugCCQs of Grout I I In0.1 ion AppU rox. Depth I I Eastern SurfaSoul Installed by � UI�Ip��I Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction C Well Diameter Sealing Material a Depth Depth _ Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of and to a depth of 3 feet: Water table depth SEPTIC TANK O Typs/MI9 CapacityNo. Compartments PKG. TREATMENT PLT. C Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C No. g Length of lines Total length/size FILTER BED O Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number \`'( SUMPS LI Distance to nearest: Well Foundation Property Lira \I DISPOSAL PONDS O I hereby unity, that I hew prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and fes. rules and regulations of the San Joaquin County LV'1 Hone owner on licensed agent's signature comfort the following: '9 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such menner as to become subject to workmen's compeofation laws of California." Contractoi s hiring or sub-contracting signature unifies the following: "'t unify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman'a compensa- tion laws of California." The applicant last call lest all required inspectio,n�s,Com/ytete drawing on reverse side. Signed x _-..... C. l'-••rhe. Title: C.! / ✓/ 7/// _ Data. z FOR DEPARTMENT USE ONLY APpi sti ccepted by e-+ Data S Ann1 �Z r Inspection by a Final Inspection by C" Date;,}tel Addilioeal Comments: % 2 C Applicant - Return all copies to: San Joaquin County Public Health Services def �. qa_ Environmental Health Permil/Services � (.C/✓" 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388FEE vL •� NFO AMOUNT DUE AMOUNT REMITTED CASN RECEIVED BV DATE PERMIT NO. N in . EM ilea{aEv.rix er '7, fX 14 a tel. of E