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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTpy ES 4�a7 ENVIRONMENTAL HEALTH DIVI UU 445 N SAN JOAQUIN, PHONE (209)ITA }$0 P O BOX 2009, STOCKTON, CA llyy u�� PERMIT EXPIRES 1 YEAR FROM DAT �S�11fn-- gIO.3O (Complete in Triplicate Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /'� / Job Address � Q'��7 q'� S�-mss City_+A Lot Size/Acreage (� Owner's Name (�'`-awl\L LY>-:?1�l Address Seey �e_ Phone Contractor r �7^ _Address �S" t Irk-4-i— License No. 30S! )=2 i Phone TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, ❑ Industrial ❑ Open Bottom ❑ Manteca Ota. of Well Excavation s �:e .5qa ,ypf.r�We11 Casing fl Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casings'.f s•,c$p�tiliSahons I'1 Public ❑ Other f1 Delta Depth of Grout Seal `�jj�^}�'�J� ryp"!In Grout I I Irngauon __ Approx. Depth I I Eastern Surface Seel Installed by .1N �;r W Repair Work Done LJ Type of Pump Scaling Well Destruction ❑ Well Diameter Material A 44— Depth Filler Material A Depth rtl/It'll; r ` TYPE OF SEPTIC WORK. NEW INSTALLATION X- REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted!( public sewer is Q Q��p available within 200 leet.l Installation will serve: Residence _ Commercial_ Other - -- ` Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: r4fXiJl Water table depth c/ SEPTIC TANK QL_ Type/Mfg �'� t-'-C- Capacity /bEiU No. Compartments 1-71 PKG. TREATMENT PLT. ❑ JJ1 Method of Disposal r Distance to nearest: Well _saalr�-,L_ Foundation� Property Line 41=G ' LEACHING LINE to No. & Length of lines c4c.) Total length/size FILTER BED Ll Distance to nearest: Well Foundation 'Zr"• r Property Line ity>' Vl SEEPAGE PITS W Depth .:a� Sire ( 2/ _ Number o� SUMPS LI Distance to nearest Well / `% Foundation � Property Line �Ck, � DISPOSAL PONDS ❑ 1 hereby certify 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 must call r all require m ions. Complete drawing on reverse side. C� Signed x HL nj - Title: OL Q t-7: Date: 7 •�l -moi y _ FOR DEPARTMENT USE ONLY 7 Application Accepted by C _ Date 'L Z" C) 9,08 7 t r Grout Inspection by ?u+� Uate �- Final Inspection by -� �Z YLT/c�CZe•- • r �� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San ,Joaquin, P O Box 2009, Stkn, CA 95201 FEE 1�Z I I INFO AMOUNT DUE AMOUNT /REMITTED /C/A� EC)IVED BY DATE PERMM11 NO, 'H ta.2�laEV.irnsr 0 I /7, C , / > -Ally/ �H 1624 VVV !iL I