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`� - APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE(209)469-3420 P O BOX 388,STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Tripli',cate) 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 Regulaliions of S�art Joaquin County Public Health Services. l I _ ik I Job Address I I' �r Lam.- ?' i'� f��'%- C,ly '�Ire!i4%;Ijc /L Lot Size/Acreage Owner's Name .L TY-L Cl $ 1)71"y Z. e'CIZA.Address zC" f /FIr S S/c_,t {C..1 jr f_-L":'(-Phone ' "'-Ti1;viSC�r�4;a lt.. i,,�Lt`iuri'. i�s•I�-i (� �r''rl�-' i--iZr�O l'[ i�CG•'� [/�l ��/-�- fU� 1 Contractor f�Yl-1 C Fr:•�,ru�t =r..z.�. �, r -, 1 _ Address4.)/ IlJ t'r,c�r.c-S S<.ri., rl %"`LiefnseNo. r `7ZI � Phone `!! TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT (1 DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION G SYSTEM REPAIR 0 OTHER 9-,, Monitoring Well E7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I�DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL -----j,OTHEAk WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i f.l Domestic/Private LI Gravel Pack L7 Tracy Type of Casing- .r Specifications I't Public f_1 Other fl Delia Depth of Grout Seal 7ii2 -IC,L Type of Grout 11 Irngatson _ Approx. Depth I I Eastern Surface Seal Instailod by i Repair Work Done 0 Type of Pump H.P. 1) SiatrilWork Done Well Destruction ❑ Well Diameter Sealing Material i DepthlI{; i3 r>-1 (.'ri'r7'r _ lyre T7�If rlr.c Depth _ Filler Material i Depth II ? TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION I IE(No septic system permitted it public sewer is i !� "available within 200 feet.I Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 4 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal # Distance to nearest: Well Foundation Propeny Line LEACHING LINE Cl No. 6 Length of lines {Total Is i FILTER BED ❑ Distance to nearest: Well Foundation I} Property Line SEEPAGE PITS 11 Depth Sire �I Number SUMPS Ll Distance to nearest: Welt Foundation �N Property Line DISPOSAL PONDS ❑ I I 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 pertorlmanca f 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 o} 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 gat! or all required inspections. Complete drawing on reverse side. Signed X Title: C YC �'t Date: -e-) - 1 c�� I FOR DEPARTMENT USE ONLIY Application Accepted by !`Date I' v �L Area -36 C I 1 Pit or Grout Inspection by Date Final Inspection by Data i . Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services j Environmental Health PerrniUServices 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388FEE e^ INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY.� DATE PERMIT NO. cl EH 13 24 IREv.liMsi EH 11.ap G�. l�� Z �✓ `��1 l �I/)l._ � �r V `/ ��-1 • ZC) Q