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r APPLICATION r SAI OAQUIN COIINTY PUBLIC HEATMWERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 } i 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 3862 and the Rules and Regulations of San Joaquin County Public Health Services.. Job Address `QQ10�___ /FST �,CEEyrdO✓f�� City .✓ Lot Size/Acreage Owner's Name AAnVhr,1&Z Ao%T CO. Address 2 _3"sk-<a- F"I"lle+ Phone Contractor P�[r�flnf Address _46'. License No. PhorteCZo9� S- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 501L t-%0Ef,,60THER>g- Monitoring Well .❑ DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES A fA DISPOSAL FLO._A Fd PROP. LINE � 10 FOUNDATION AGRICULTURE WELL A/—V A/-VOTHER WELL ^� PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial 0 Open Bottom ❑ Manteca Dia. of%kW Excavation {o•S" Dia. of Well Casing NA FI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ NA Specifications—N. V1 Public 0 Other n Delta Depthiof Grout Seal .1jZe�eF' Type of Grout I I Irrigation 5.r Apprex. Oepth I I Eastern Surface Seul Installed by Repair Work Done 0 Type of Pump NA H.P. State Work Done Well Destruction O Well Diameter Scaling Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I Wo 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 sail to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS. 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen'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 ust all r4&77 i Inspections. Complete drawing on reverse std Signed Title: _. r3�YN.atr� Date: l) - f FOR DEPARTMENT USE ONLY Application Accepted by ' Date- Zv 9 Area U` Pit or Grout Inspection by Date Final Inspection by Data lU f Additional Comments: Applicant - Return all c ies to: San Joaquin County Public Health Services �I Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK O /C'ASH RECEIVED BY DATE PERMIT'N0. . EH 1324 4NEV. ti 31 J �P �/ (D/Z f 1 0 7 `O EH t4.26