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APPLICATION SAN JOAQUIN 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 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 Earl— Frt moo I ST"er City q0000111 Lot Size/Acreage I;L; l 1301 Owner's Name glut C� VV i—i p _ Q� �NOcftiC� Address SQM'f Phone -I q 6- gQ75 AMOUNT REMITTED gattcho CoNdOvq Contractor IMI'r ( rA M ^NV•Address P•0, 84 31 9 V-7141 License No. b 7.Z 6 f 7 Phone(alt ,gS; -9 D TYPE OF WELL/PUMP: NEW WELL � WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ 131&-s PUMP INSTALLATION Z SYSTEM REPAIR ❑ OTHER !toil Well O seal oMr+17y 5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 19_ FOUNDATION 1;J AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom C: Manteca Dia. of Well Excavation Dia. of Well Casing N Domestic/Private ❑ Gravel Pack Tracy Type of Casing_ `-' Specifications - 1'I Public ('1 Other 1, Delta Depth of Grout Seal ' �y�% Type of Grout d I I Irrigation _ Approx. Depth IA Eastern Surface Seal Installed by N' 4� GeO�T Repair Work Done 0 Type of Pump H. P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ' i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public fewer 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. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sue Number LIMPS LI Distance to nearest: well Foundation Property Lina DISPOSAL PONDS ❑ L: 44 t 1 1 hereby certify that I have prepared this application end that the work will be done in accordance with San Joaquin county ordinances, state laws, end rules and regulations of the San Joaquin county f\� 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, 1 shall noJ J employ any person in such manner as to become subject to workmen'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 workman's compensa- tion laws of Cali The applicant us all or all r red c to mplete drawing on r se side. q fC✓�J'� C �li�' 2 Signed Title: / A ate: J �I ' FOR DEPARTMENT USE ONLY Application Accepted by g Date C Area r �� Pit or Grout Inspection by Date l� / Final Inspection by / Data i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 5-501 445 N. San Joaquin, P.O. Boz 388, Stockton, CA 95201-0388 - r ? EM 13-24 IREV. I/ n S. EM 14.20 FEE INFO AMOUNT DUE AMOUNT REMITTED r %v L " CK # CASH RECEIVED BY DATE 1 t-! r __✓ PERMIT' N0. $ 131&-s `/-�1,-1z_,0 f �� do3Bt3 rn rn 2 tL