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APPLICATION FOR PTRidIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420_ f P O BOX 2009, STOCKTON, CA 95201 I z PERMIT_AMIRES 1 PEALDATE ISSUED 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 Ordinance No. 549 and 1862 and.the Rules and Regulations of San Joaquin County Public Health Services. p Job Address A • City C� AL.0 W- Loot size/Acreage i f Owner's Name ILLA 7UCCLOPME� Address+P1____e)Y 4 -C� -15-CA D1s�--- Phone 5�7 ContractorllIC.LA 1?6 KL.4EM.'1,�Address r• 7 E� License No. 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER,❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �.. .q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wait Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications � 11 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth r I I Eastern Surface Sea] Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Piller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 111' REPAIR/ADDITION I I DESTRUCTION i I fNo septic system permitted if public sewer is available within 200 feet.) T Installation will serve. Residence Commercial Other Number of lilviinq units: D d E Number of bedrooms i Character of soil to a depth of 3 feet: CJ La 4 A4 Water table depth 40. l SEPTIC TANK. 1R Type/Mfg CSN�'Me-V- 13 L- Capacity No. Compartments M PKG. TREATMENT PLT. 0 Method of Disposal -Distance to nearest: Well QQ_ Foundation 2-0 Property Line SO f _ _LEACHING LINE R 0 .No. & Length of lines � `+C7 �A l�i Total length/size FILTER BED 0 Distance to nearest. Well 10fi =in Foundation 2-f,r Property Line Gib I . SEEPAGE PITS I* Depth Sire,�� Nu her - i a , I SUMPS LI Distance to nearest: Well Foundation Property Line k DISPOSAL PONOS .❑ ' 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 Canify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of California," R _ The applica t must call for all required ins tions: Complete drawing on reverse side:�J Signed Title: _- rx oda Date: F DEP TMENT USE ONLY ` Application Accepted by oacx ,. Date �^�- req01 Pit or Grout Inspection by Date Final Inspection b Data� � iAdditional Comments: -- - - V Applicant - Return all copies to: San Joaquin County Public Health Services I Environmental Health Permit/Services 445 N•San Joaquin, P O Box-2009, Stkn, CA 95201 y FEE INFO AMOUNT DUE AMOUNT REMITTED CK RE E]VEO BY ekswOA E "�PERMI7'NO. . EH 3-24(REV.rinao�1v I' rte�7 , 9� Eh ta•is cJ l