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41 APPLICATION ' S&OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P 0 BOX 388, STOCKTON,CA 95201-0388 PERMIT EXPIRES I YEAR FROM DATE ISSUED 5 {; (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 Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �1 S. Vett t f'Q� . ...5 City S Skl() Lot Size/Acreage ft l,,� �+1 1 115 Address S 1��r �Nr3t i 20 �d one ' IS.3�3 4 Owner's Name _. Ufiry V-1 2 g z 5 r�,c t•t S r 2Z 8 qF 5-8 , r Address t License No, Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION t of Service Well ❑ PUMP INSTALLATION 7 f SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES_ ?�Qhr __ DISPOSAL FL D„ PROP. LINE;>5'0FOUNDATION 1 AGRICULTURE WELL AA_ OTHER WELL TSO PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r W 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welt Casing f:] Domestic/Private ❑ Gravel Pack ❑ Tracy t Type of Casing_ Specifications Il Public 1-1 Other Y n Delta Depth of Grout Seal Type of Grout — I i Irrigation —Approx. Depth i 1 Eastern Surface Seat installed by O Repair Work Done '❑ Typo of Pump rt H.P. btato Work no Well Destruction Well Diameter � Sealing Material i Depth LIr ✓ f .35' Filler Material i Depth C4?.I PG, F(CAWA O 1 1 1 1�-Iq o Depth I TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 INo septic sysism permitted if public sewer is .. ;. _ available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms w m y .0 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal a Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 persons subject to workmen's compensa• tion laws of California." The spplica m at all f I r ' ed inspections. Complete drawing on rower" sid + �j Signed r' ' title: �''a � ��°� _1 _ Date: �1 4 t FOR DEPARTMENT USE ONLY ] 7 I Application Accepted by<:;214 22�� Data r v�� ^i Area Pit or Grout Inspection by Date Final Inspection by Oats Additional Comments: COMPI,�� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services .+, 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED RY DATE PERMIT'NO, F INFO CASH EN t42e //nEM13.2.111EV. nen F ' � f� (Q J � �asr3 ax