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APPLICATION SR# /1 SARI JOAQUIN COUNTY PUBLIC HEALTH SE ENVIRONMENTAL HEALTH DIVISION Wal# ` 445 N SAN JOAQUIN,PHONE(209)469-34 0 P O BOX 388,STOCKTON,CA 45201-038 FAC ]!/)/f<j � �./�r s�• ) J2TRIIIT. S ,Y�R ��QIS DATE i1subw b ,7 I (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.•!itis 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. Job Address 1 'fir ` �� a7 /�-�- CCiity 'L-:^e Lot Siae/Acreage &;[-e Owner's Nams.%F� !n Address J f j G y` Jed1 '% Phone - Conitactor � Address 1 f C ::� ,j ,License No.r� '/ Phone G�iE TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C3 SYSTEM REPAIR ❑ OTHER ❑ Itonitering Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPJjA i2 PROP. LINE FOUNDATION AGRICULTURE WELL OTH PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP ECiI 0 Industrial ❑ Open Bonom 11 Manteca Dia, of Well Excave � 1994Din I of Well Casing 173 Domestic/Private ❑ Gravel Peck ❑ Tracy Type o} Casio Pu CO Nywocifications I'1 Public f 7 Othe+ fl Dena Depth of Grou 0�F I,�VQ1�of Grout ApproxDeth I I E I 1 Irrigation . pastern Surface Seat Ins,alwd by ;T7 IV, Repair Work Done (3 Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing fateraA Depth —'�'— Depth Filler lfst:erial ; Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo soptic system permitlad if public aewer it available within 200 feet.} snatrslation will serve: Residence— Commercial_ Other �7 Number of living units: Number of bedrooms $ - Character of soli"lo.a depth of 3 feet: Water table depth SEPTIC TANK O TVWMfg Caprcay No. Companmenn PKG.TREATMENT PLT.❑ Method of D*osal i • Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length o1 lines Total longh/size FILTER BED 0 Distance to nearest: well Foundatwn Property Line SEEPAGE PITS it Depth Size Numbef SUMPS LI Distance to nearest: We1I Foundation DISPOSAL PONDS ❑ P►opeety Line ----- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. stale taws, and rules and reguiatiorls of the San Joaquin Cowltr Hone owner or licensed agent's signature carinae the following: •'I certify that in the pettormance of the worst for which this permit is issued,I shall not amp,oy any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-con signature ~ ossifies the following:"I certify that in the perlormonce of the worst tot which this permit is issued, I shat,employ per subject to wo+kman'a aompanp, tion taws of Calitomla." The appticani at call for all required inspections. Com eta drawing on reveres side. Signed Title: Date: FOR DEPARTMENT USE ONLY App t" ecepted by Orta Area r Inspection by Final Inspection by _ Data,- 'el J" Additional Comments: 2 . Applicant - Return all copies to; San Joaquin County Public Health Serviccs S,,;z 074 Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 / r 1 S.Z�i7/ FEE "} INFO AMOUNT DUE AMOUNT ltEfYt1TTED CASH RECEIVED By DATE PERMIT'NO. ljo'� • IN 13•24 IREV,1/1151 �y EM 11.20 �1d. d