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APPLICATION _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388,STOCKTON, CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 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 Titlea tion 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. rf5 19-20 _ Job Address 12991 E 1'ET7i F►AA11LIJ �7HS�E,HAKUE'f�I��ty SDI Lot Size/Acreage 312f.AGr owns;a Name F NLE ITE�16iACNER Address Phone( G o "IbD1D BidP.� RcE r.� 3686(�I S Contractor A Z Address 31? Jl F N License No.l�1P3�J Phonic TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out or Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ �- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 CI Domestic/Private ❑ Gr" Pack - ❑ Tracy Type of Casing- Specifications l'I Public 1-1 Other fT Delta Depth of Grout Seal Type of Grout - I I Irrigation _Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done U Type of Pump M.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth _ filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public serves, is �5 FERC"TIOU -TEST. + 4OLCS M5 95 -20 available within 200 feat.) Installation will serve: Residence_ Commercial_ Other _ Number of living units: _ Number of bedrooms - Charaeter of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. g Length of lines Total length/sizs M FILTER BED ❑ Distance to nearest: Well Foundation Property Line RECEIVED SEEPAGE PITS I I Depth Sire Number 5 _ SUMPS LI Distance to nearest: Well Foundation Property Line tmq OAQUIN COUNTY DISPOSAL PONDS ❑ °' c 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqutt�coP4!RVNf WAL$H"leI"JVO9i_14 rules and regulations of the San Joaquin County Home owner cr licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mannar 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 performance of the work for which this permit is issued,I shag employ persons subject to workman's compensa- tion laws of California." The applrcan must call for MI required inspections. Complete drawing on reverse side.' 13reffQZZCDate: 94 t&-y,5 Signed red.: Q FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit w Grout Inspection by / Date Final Inspection by n l Date (9 Additional Comments: lam/a 9S y h4N/t!Ste, d- " " ZV 1/SZ✓ ! 2 '� ZA Applicant - Return all copies to: San Joaquin County Public Health Services A,40 Ze 0.t/' Environmental Health Permit/Services T D t e 9(�(f ��YY 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 Too ( o [ LFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. n 7, INFO ^� ✓- .� r _ i r , 1 � r0