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�../ APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Ms `?q- C I(,P 445 N SAN JOAQUIN,PHONE(209)469-3420 P 0 BOX 388,STOCKTON,CA 95201-0388 ep '� PERMIT EXPIRES 1 YEAR FROM DATE SSHF�# --``��--/��--yy�� --++(('� 70 f (Complete in Triplicate) AID # _�e,� � = Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described Tbisvppli tion is made in compliance with San Joaquin County Development Title Section 9-1110.3 and Sec' 115.3 an es a d gu ations of San Jo quip Coadt P. IJ2 !(} �4-p 1 C /ay Q V7.0 F Lott751fle 8 Job Address City L Owner's Name `/• h' a TO W) r Y Address -3 49 �n... s � r Phone 3 -ZJ Z 1 Contractor v. Fro .r Address 4Gt1$ ✓'ona� Av r.License No. 1��35 j Phone .. TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 2k Monitoring Well ❑ \ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ -v<vcc 'T.s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ea INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public (-I Other n Delta Depth of Grout Seal Type of Grout p I I Irrigation _Approx. Depth I I Eastern Surface Seel Installed by .y Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materia.. a Depth \'VI Depth _ Filler Material a Depth - O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public wwer is available within 200 feet.) Installation will verve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of w8 to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Dis'pos'al Distance to nearest: Well Foundation Property Line ^3 AA 11-- LEACHING LINE ❑ No. b Length of lines Total length/siz 4PAa FILTER BED ❑ Distance to nearest: Well Foungation Props' a SEEPAGE PITS 11 Depth - Size SUMPS LI Distance to nearest: Well Foundation T Is i..._ _. \ DISPOSAL PONDS ❑ A( rF1-.141, I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin c r({1/� nancas, state laws, and \\ rules and regulations of the Sen Joaquin County �N 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 applica uat call or all raquyed ins ctions. Complete drawing on rayerse side.. Signed Y Title: //f/-Cay+ T( Data: FOR DEPARTMENT USE ONLY Application Accepted by Date ~ M; ) Pit or Grout Inspection by Data Final Impactio b JkJZAre, Data Additional Comments: c IZE'f 2-r ir Applicant - Return all copies to: San Joaquin County Pub ealth ervices Environmental Health P it/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 ee^ �pL 7FEE i4 INFO AMOUNT DUE A OUNT REMITTED CASN RECEIVED BY . DATE PM EN7alEV.ti.sl EN I4L)J - 6 /D a