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APPLC<ATION NIP/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)40 - 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 Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. [. Job Address f 919-7 Wes+ 4,t yl C11y S4'oCk+0A1 Lot Size/Acreage Phdctdee1 PhrC&, q r Owner's Name Pep P.,oYS Address 31 W,,At 51her1y AVP PA— Phone If V Contractor ee-�r'a, T i0 Address 9-.365 w_r �it St'oekfe-1 License No. S/Z2-�� Phone 65-8712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION _,❑_/r{Out of Service Well O PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ill' SEWER LINES '��O DISPOSAL FLO.A) PROP.LINE t U-F+ FOUNDATION I041t, AGRICULTURE WELL — OTHER WELL�� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F.l Domestic/Private ❑Gavel Pack ❑ Tracy Type of Casing_ Specifications I'I Public IOther fl Delta Depth of Grout Seal Type of Grout I I Irrioation 6S Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump MA H.P. __ State Work Done Well Destruction O Well Diameter Neo Scaling Material i Depth Mme n Depth_ biller 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 200 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 Cl No. IS Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 subcontracting signature certifies the following: "1 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 applicantmust call for &Ir d inspections. Complete drawing on reverse side. Signed X`�� 4— �^— Title:CG'&901J ' ""?Q tT>�O�©CI/s� Date: 6 FOR DEPAfITMENT USE ONLY 9 Application Accepted by Date / r�� Arsa Pit or Grout Inspection by Date GFinalal Inspection by Date Additional Comments: �Y V Applicant - Retur 11 copies to:j San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 FEE INFO AMOUNT DUE AMOUNT REMITTED CK If ICASH RECEIVED 8Y DATE PERM17NO. Q EM 2.2 111Ev.vx / ar—7 1 R ?9 k577 -?7o