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+ ` SAN JO#N COUNTY PUBLIC HEALTH SE fiS ( � - A. E[TVIRONMENTAL HEALTH DIVISION Pabc �aallu�s 445 N SA_*i JOAQUIN, PHONE (209)468-3420 P O`BO% 2009,_ STOCKTON, -.CA 95201 G - I fstr✓ Ei -Iw PER1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Ss hereby made to Sm Joaquin County for s permit to construct and/or install the work herein described. This application in made in compliance with San JoaCui`n_,County Ordinance No. 5>+9 and 1862 and the Rules and Regulations of Sm Joaquin County Public Health services Sl{[ lt�r.{cd �"f• Lot Size/Acreage yJO�K L3cn� Pow35SNav P Citys Job Address 5 , I�U� Phone /" Address Owner's NameN ley l� Df Rc*nch�LWc4�✓ti- X57 60.Z72D Phone gSe"L 7�}S (=X LYiL(7Lv1 Address 3X41 � "9u"'jd/ License No. Contractor —... p DESTRUCTION E. Out of Service Well ❑ TYPE Of�MP NEW WELL ❑ WELL REPLACEMENT Ll Monitoring Well ❑ PUMP INSTALLATION ❑t SYSTEM REPAIR ❑ OTHERA C7COI.-Ooe S Lbcr�n95� DISTANCE TO NEAREST: SEPTIC TANK V5 f- -tU SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ac"''t"T'C AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N 0. Dia. of Well Casing L) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications 1. Type of Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal N A. Type of Grout G I'1 Public Il Other fl Delta 1 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by of Pump N`' H.P. State Work Done Repair Work Done ❑ Type N Well Diameter pe'" Sealing Material i Depth Well Destruction ❑ , Depth Filler Material i Depth ltJ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I ahosapficsYstem vaitabe within 200 ffee1t'ed if public sewer is Installation will serve: Residence_ Commercial_ Other - �J Number of living units: _ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT.❑ Property Lire Distance to nearest: Well Foundation Total length/size LEACHING LINE ❑ No. i Length of lines Property line FILTER BED ❑ Distance to nearest: Well Foundation Pe Y SEEPAGE PITS 11 Depth Sue Number SUMPS � LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ;,1 he certify I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state scan, and '*„'rules and regulations of the San Joaquin County :'Nome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not =sttiploy any Person in such manner as to become subject to workmen's wmpensation Wws of California." Contractor's hiring or subcontracting signature >'-eert�es the personfollowiin "1 certify that s o performance of the work for which this permit is issued, I shall employ persons subject to workman's dompen6a tan laws of California." The appliunt,gt s call for all required inspections. Complete drawing on reverse side. �{/(�j� fC,�`/l Date: Signed X1(.J�A�,1 y.(�= Title: �` ii FOR DEPARTMENT USE ONLY �/ T -> Date I �7 Area CflIZfR/QtEJ Application Accepted by a0 - Pit or Grout inspection by Date Final Inspection by Date _ Additional Comments: Applicant - Re n 1 copies to: San Joaqui ounty Public Health Services .�G Environmental Health Permit/Services 445 N San Joaquin,' P O Box 2009, Stkn, CA 95201 f/ 1 FEE CK RECEIVED I y DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED �/C.p 11 EH IT-24 t11EV.r IN el Nor,� � ! C •� n.Lik17/ !� �"3V2 EH 14.36