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A1111LICATION FOR PERMIT SAN JOAQ11114 (:OUNTY PUBLIC HEALTH SERVICES ENV 111014MENTAI, HEALTH DIVISION 1601 F. 11A7.11,T0N AVE. , 1'11ONF, (209)468-3420 1.1, (1 Itf)X 2000, STOi;KTON, CA 95201. kFAVJ'y 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 work herein described. This $ application Is made in compliance with San Jnagnln County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ) / ,///,�{q_ �d- Lot�•,�,---------- Cityl�w7yJ/iSize/AcreageJob AddressOta n Owner's Name — Address _.G - -. --_L—1 - PhoneConlraclor7 �� ilLti(L� ... -Addi ,0d�R•S, L -p-r-1License No.W_JJ _(_Phone AL_r_�L- TYPE OF WELL/PUMP: NEW WELL ( I ELL. REPLACEMENT (1 DESTRUCTION l l Out of Service Well PUMP INSTALLATION f 1 SYSTEM REPAIR ( I OTHER C1 Monitoring Well [� DISTANCE TO NEAREST: SEPTIC TANK SFWER LI .S _._ DISPOSAL FLD. PROP. LINE - FOUNDATION _ AGFlICULT E _LL_—_�_ OTHER WELL PITS/SUMPS _ INTENDED USE ; TYPE OF WELL PFlOBLEM AREA N_ STRUCTIO_N SPECIFICATIONS [ I Industrial O Open Bottom 1-1 Manteca is of Well ExcavTtion Dia. of Well Casing ( I Domestic/Private 0 Gravel Pack 1 I Irl ry Ivpe of Casing. ___- Specifications --- 1'1 Public I 1 011ier 11 Delta I epth of Grout Seal •__—_ Type of Grout I I Irnttauon Approo, Depth 11 FnRlorn urface Seal Installed by _- Repair Work Done 0 Type of Pump __.-__ 11 P -. -. _- ---- State Work Done Well Destruction 0 Well Diameter __- _ _ V<e)ing terial & Depth Depth _ Flller linterinl & Depth -..�.- TYPE OF SEPTIC WORK: NEW INSTALLATION I f FlEPAIFl/ADDITION I I DESTRUCTION I I INo septic system permitted it public sower is vailable wp lin 200 eet.l t ~ �+ ' Installation will serve: Residence v Commercirl 1' Other .__._,__ I1 t Pr_' % S y Number of living units: - Number of bedronrnd Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK n Type/Mfg _{ C_l? 'f.V''' 4..... Ca parity._f�i.U-✓ No. Compartments _ PKG. TREATMENT PLT. D (( _ Method of Dispo al Distance to nearest: Well`].��ft.. Foundation _: .- �14- Property Line i LEACHING LINE Ll No. & Length of lines ]L /. _ otal length/size FILTER BED CI Distance to nearest: Woll _,SCS Foundation _� Property Line SEEPAGE PITS 11 Depth �_� Size __- r.L1 _ —_- Number \ J Y� SUMPS LI Distance to ne rest: Well AW.1� _ Foundation-4a-- Property Line —VeIL DISPOSAL PONDS Ll !! I hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sari Joaquin County Home owner or licensed agent's signature cenifies 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 mariner 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 ilia work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 1110 applicant ust call foye=10-0. Inspections. Complete drawing on reverse side. Signed X f � .. ------ Title: r�- -- Date �-- `- ! :)FOR EPAflTMENT USE ONLY C1-C Application Accepted by _ ::-__._— � � "``f`"`'� Dat e r�O Area - t �� Pit r Grout Inspection by/ / t�L . . Dain / 6- Final Inspection by �. .. �'� ' �L Date Additional Comments: — ._._..__...--_ --• - Applicant - Return all copies to: San Cwmty Public Health Servic-a, F•rtvironmenta) Health Permit/Services 1601 F. Raz-lton Ave., P 0 Box 2009, Stockton, CA 95201 FEE CY,1Z'----------- INFO AMOUNT DILE 4MOlr1Jf f1FMIiTEt? RECEIVED BY DATE PERMIT'NO_ CL$H EH 1324IREV.1in51 �( L)(,) (��;t r , '•Q L. ''- .