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IAPPLICAT10N FOR PERMIT y � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1 P 0 BOX12009, STOCXTON, CA 95201 (209) 468-3447 a":'� R PM DATE ISSUED, (Complete in Triplicate) `. Application is hereby made to San Joaquin County for a permit to construct and/or inata.11 the work herein described. This application is ttmde in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San' Joaquin County Public Health Services. Job Address _ 1 7 C.'/�fIcPA 1-4, City S'YW6TGAAgt SiZe/Acreage 'I Owner's Name S A Address S Phone 93l— Z-V Contractor_EZ-0YQ Ak"O.D �Address Al 4DeGB�,Pr ,�4r1,6 License No. 5�3��-7b Phone - TYPE OF WELL/PUMP: NEW WELL ❑ s� WELL REPLACEMENT C_l DESTRUCTION 0 Out of Service Well Cl PUMP INSTALLATION O i SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation -' Dia. of Well Casing U Domestic/Private 0 Grave! Pack ❑ Tracy. Type of Casing Specifications ❑ Public I'1 Other ❑ Deltas Depth of Grout Seal Type of Grout M Irfipation Approx. Depth ❑ Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material i Depth 4 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION RE'PAIR/ADOITION DESTRUCTION CI (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: . Residence 1 Commercial! Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: L h Water table depth A,�-,rSEPTiC TANK. ❑ Type/Mfg P9L-z__ `G Capacity__gL ® No. Compartments 'Z— r PKG. TREATMENT PLT. Cl Method of Disposal , Distance to nearest: we B f Foundation S Property Lina 62? r 1m LEACHING LINE No. & Len Ih of'lines �- /p0 g Total length/size--- FILTER ength/sire FILTER $ED �:"`-�.�] Distance to nearest: Wel 'S'l �1'J471-1"Foundation � Property Line /a SEEPAGE PITS ! Depth Ih Sixep._ 4._ _ 4 22 it "" NLrmber. SUMPS LI Distance to nearest: Well O` Foundation 7_5" Propeity Line /r DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and thalt the work will be done in accordance"with-San Joaquin county ordinances, state laws, and ° rules,and regulations of the San Joaquin County — " Homeowner or licensed agent's signature certifies the following; "I cartify 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 iork woman'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 California." - .r.."The applicant must call for all required inspections. Compile drawing..an-reverse side,.. Signed Title: Date: FOR DEPARTMENT USE ONLY APPlication'Acceptad Area Z (?i; it or out Inspection by �' ^Cj Data_ Final inspection by_ _. �� Data Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONM£NTAL'IHEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE-_-. ;__.. :..CIC -- INFO AMOUNT DUI AMOUNT AEMITTED f CASH RECEIVED BY DATE PEAM17CNyO, . EH 13.24IREV.FNs) 'I41)