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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 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 Development Title Section 9-1110.3 and Section9-1115.39-11155.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address / 0� W'<51' i �. F►04� City 1 �E�— Lot Size/Acreage ] Owner's Name MQ n V% tyA L D 1G Address F-0, Be i I f� T ra i ci '374 Phone )L7 Contractor rimer- 4 {i &NAbdress F1 License No(O�l� Pho49/6 g-5Z- TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service We12 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR F-1OTHER! O.SD Monitoring$Well CJ DISTANCE TO NEAREST: SEPTIC TANK � V SEWER LINES _ V/A^ DISPOSAL FLD. N PROP. LINE 1 FOUNDATION ® AGRICULTURE WELL OTHER WELL i F0 PITS/SUMPS ✓�1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-I Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t.l Domestic/Private ❑ Gravel Pack 5(Tracy Type of Casing_ " Specifications 1 I'l Public la Other fl Delta Depth of Grout Seal cc) —30C of Grout 1�OrT�QNr� I l Irrigation Approx. Depth I I Eastern Surface Seal Installed by MSI t"0,4r � - — Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sesling Material i Depth Depth _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within Zip feet.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 11 Distance to nearest: Well Founoatron 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 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 persona subject to workman's compensa- tion laws of California." The applicant al uired ins tions. C late drawing on reverse side. Signed mu sal r Title: _&tZr _J� fJGI s.�`_ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ��O 9 Area Pit or Grout Inspection by � � ate Final Inspection by Y, t Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services S 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 3` ra^ INFO FEE AMOUNT DUE AMOUNT REMITTED CK//C2ASH FEECEEiVVfED BY DATE PERMIT- NO. � Err 1 1•24 IrIFv,1/0151 ` f yr o(J .�O j a EM 14.2