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Q,L10� APPLICATION �J. SAN JOAQUIN COUNTY PUBLIC HEALTH SE VICES 00 ?S' ENVIRONMENTAL HEALTH DIVISIO AID # Ql O �tti 445 N SAN JOAQUIN,PHONE(209)469- 0 u P 0 BOX 388,STOCKTON,CA 95201-038 FAC # S� -PERMIT ES 1 Y F DATE I (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 '39 _ E y (a City Lod I� Lot Size/Acreage Owner's Name i' �1 —`� G` � Address Phone 1g Contractor t ic-p— it r Address ___PQ A1)\0 (9ZA License No. OC Phone —7Z') TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Hell O PUMP INSTALLATION ❑ SYSTEM REPAIR L-1 OTHER C Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing C) Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'I Public .I Other 11 pelta Depth of Grout Seal Type of Grout 11 Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material i Depth Depth _ Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOPTION ( I DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) Installation wig serve: Residence Commercial_ Other Number of Going units: __L_ Number of bedrooms 3 Character of soli to a depth of 3 feet: S cAd o W! —Water table depth SEPTIC TANK CType/Mfg a Capacity {a—� No. Compartments �- PKG. TREATMENT PLT. Cl ti Method of Disposal Distance to nearest: Well n n rn Foundation - 19 Property Line s LEACHING LINE v"No. b Length of lines 7ptal length/size f FILTER BED ❑ Distance to nearest: well Jj))c5 f Fourwation _ (L� Property Line q SEEPAGE PITS i I Depth Size �r - Number SUMPS l�Distance to nearest: Well CJ Foundation ( h 0' Property Line 4_ � DISPOSAL PONDS 0 PIAY I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaqui � � state laws, and ly rut"and regulations of the San Joaquin County AA rr''�(�+ Home owner or licensed agent's signature certifies the following: "I Certify that in the performence of the work fm"9thia§err19**sued, I shall not employ any person in such;manner as to become subject to workman's compensation laws of California." Conir"N'5Wittgracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall empI"LIU s compensa- tion laws of California." SCES The applicant must cell for all required inspections. Complete drawing on reverse side. ENVIRONMENTAL HEALTH DIVI I0N Signed Title: T'l 4 M[.fescy Date: FOR DEPARTMENT USE ONLY / Appli Accepted byf �� Date Arsa �_ I Z/ ' t t�6r;by (Date �� Final Inspection by Additional Comments: O-P Applicant - Return all copies to: San Joaquin Co y Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-03 C ICKFEE AMOUNT OtJE AMOUNT REMITTED CASH RECEIVED 8y DATE NFO ttyNtr1EV.rinet �`IS t f Vv 2 S qq a" in a