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e �.� APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ` 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 vork herein described. This application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and egulatlons of San Joaquin County Public Health Services. n �j /gP 7708009 Job Address 2Jai IVOWAI 27u6rLE2MAA( f City s�acK7aK Lot Size/Acreage }� ¢ Ct1C,70JV,*_ o �IFND) ^p �+ *lam L Owner's Name /r �`s'�• Address 77 PA011-E SI• O F Phone s•97+ >(O Contractor Address License No. Phone to. 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 FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (� Il Public n Other n 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 H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION X DESTRUCTION (No septic system permitted if public sewer is 'L a Mable within 200 feet.l _ Installation will some: Residence_ Commercial _)L Other 1Lt~�_ L•�6�-C/'`�U3+-- Bti� L/��G//T�'K/!r Number of living units: _ Number of bedrooms - Character 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 too LEACHING LINE P( No. 6 Length of lines Total ength/size /d70 o0C'T FILTER BED 10 Distance to nearest: Welly''O rj Foundation IS/rl Property Lina 1-_ SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and sK rules and regulations of the San Joaquin County !Yr Home owner or licensed agent's signature certifies the following: "1 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 for all required inspections.-Complete drawing on reverse side. Signed %�5 v � Wr2 Title: AC)671/V4l�� Date: —9/ FOR DEPARTMENT USE ONLY Application Accepted by f� Date�� Area Pit or Grout Inspection by Date Final Inspection by /• /�/ Date �S l Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Bervicea 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. i CIN!?F 'NF1. } ` �A 1t °/-��' Q{ - . EH t}741REV.rr n513a._ ' 1. 1I LA0 QAA �d U47` 1 7� 11� ''I(K-I