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NEW APPLICATION .. SAN JOAQUIN COUNTY PUBLIC HEALTH SE ZV%# a w.auiae�I o ..ter_ ENVIRONMENTAL HEALTH DIVISIO AA uu KZ 3 445 N SAN JOAQUIN,PHONE(209)469-3 AID R P 0 BOX 388,STOCKTON,CA 95201-03 8CaC 8 PERMIT EXPIRES 1 YEAR FROM DAT ISSII (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 TitleSection9-1110.3 and Section 9-1115.3 and the Rules and Regulations of�San �,Joaquin County Public Health Services. Job Address 1 SI SC (1Cr R`� City-lr /- -C, 1- Lot kS�ize/Acreage / Owner's Name �O oX- Y G UQ>1 J� i G 1 Address \ S s nG E 1 1D 1<f V1 C) Phone 'ZO fJ Contractor �-F\ Qacwoe_ Address -11Y-29(54(A\G� Ka License No. 4� S 4Z, Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL'k OTHER WELL® PIT SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION6` psg3as--4 as� ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation- VJfiQell Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ t% � tions 1'1 Public 1.1 Other n Delta Depth of Grout Seal r'= I,ITyp�.�Jt v I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Q t.N.:i0W AI State 8'kbr � Type of Pump N.P.Re sir Work Done Uf�rfTFi(iiV'{Jili1' " Well Destruction ❑ Well Diameter Sealing,Material i Depth ,,,ylRr0NNI Depth _ Tiller Material 4 Depth - l" TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer Is r ,� available within 200 leet.l Installation will serve: Residence �L Commercial_ Othar Number of living units: P Number of bedrooms_. 2 Character of wd to a depth of 3 feet: _ Water table depth SEPTIC TANK 13Type/Mfg efv_ Y Capacity I SO6 No. Compartments Z PKG. TREATMENT PLT. ❑ -- -. -Method of Disposal Distance to nearest: Well ` Foundation Propedyr Line LEACHING LINE Cl No. 6 Length of lines Ik Un total length/size O FILTER BED ❑ Distance to nearest: Well Founaation r Property Line 460'0 (� SEEPAGE PITS 11 Depth )6 Sire �( I ea )0 Number � ,,�.,ae�.�� T �� SUMPS LI Distance to nearest: Well Qf Foundation r Property Line.��a— fg✓i✓. ° _ DISPOSAL PONDS ❑ I hereby cenity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or 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 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California."/ The applicant mus 11 for NI require inspection o plate drawing on reverse side. ,n SignedY Title: U ��2 Yc Date: FOR DEPARTMENT USE ONLY Application Accepted by C s � � Date res Pit or Grout Inspection by Date Final Inspection by Dets Additional Commems: �/� -�� F� /.��i^*�✓ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388FEE " -I N ', INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. iasv �iea� \Y 1 r I ( L r_ //rf /r` I l/ -_7 --t