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�.V APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMS ON MJ 14- 01k, 445 N SAN JOAQUIN,PHONE(209, 4 3420 P 0 BOX 388,STOCKTON, CA 95201-0388 S IT IRES 1 YEAR FROM DATF ISSIIID 5 X70 (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 Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 970 K-r 1 �.1 IJV Cyi H C GN�+ Lot Size/Acreage 9 .86 1 Owner's Name I b 1 d f'0 W 1 f Y Address 33 Phone V43 - 404 1 Contractor • r. - �; Y.ti r , Address ybv S .'Q v -n '.aa Air. License No.11'.35 1 Phone t M TYPE OF WELL/POMP: NEW WELL ❑ - WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IV Monitoring Wei--_a_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD_ PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -- r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public f-I Other fl Delta Depth of Grout Seal Type of Grout I I Irnuauon _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done J Type of Pump M.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth _ Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ —� nmgwitposel Distance to nearest: Well Foundation /� 7' LEACHING LINE ❑ No. 6 Length of lines �alpi eng1h4ai>Q FILTER BED ❑ Distance to nearest: Well Foundation HH'IVV ( � Ll HEALT � — SEEPAGE PITS 11 Depth Size Number HEALTH SUMPS LI Distance to nearest: Well FoundationProps y Line DISPOSAL PONDS ❑ 1 hereby certify that I hew prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lewd, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature conn"the following: "I certify that in the Performance of the work for which this permit is usUdId. I Mall 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 unify that in the performance of the work for which this permit Is issued. I shall employ persons subject to workmen's compensa- tion laws of California." The apple: atcallIm MI rApfired inspections. Complete drawing onfr�9verse side. SignedlX./ WyL �/�.Qw Title: !'r 1,0 . r —� Dau: ?— ZU;I ly FOR DEPARTMENT USE ONLY --f Application Accepted by Dans 9t) Ann Ph or Grout Inspection by U Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388 e a y^ZZz. NFEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. n EN 13Q4,