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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV-ICE3 Ii ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 ; (209) 468-3447 PERMIT IRES 1 Y R I SU,-n (Complete in Triplicate) , �. Application is hereby reads to San Joaquin County for a permit to construct and/or install the vork herein described. This application is [[fade in compliance with San Joaquin County Ordinance No. 549 and 1862 'and the Rules and Regulations of San Joaquin County Public Nealth services. Job Address j� �� lit% , -110A/�e— G�_ City 5, ''J Lot Size/Acreage _/Fa .3'/0 _ u } Owner's Name I�I V Address -5' Phone Contractor E.� -. Address � E L+cense"No- �'-Phone I TYPE OF WELL/PUMP: li NEW WELL C] WELL REPLACEMENT 17 DESTRUCTION LI Out or 8eryice Well 0 PUMP'INSTALLATION 0 SYSTEM,REPAIR D OTHER ❑ Monitoring Well Ll 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 I Ll Industrial ❑ Open Bottom - ❑ Manteca Oia. of Well Excavation Dia. of Well Casing ' O� U Domestic lPrivate ❑.Gravel Pack .'. L7'Tracy Type of Casing Specifications I - A Public (1 Other „» ❑ Delta Depth of Grout Seal Type of Grout CI Irrioation _I..Approx�Depth ❑ Eastern Surface Sadl installed by _ Repair Work Done 0 Typs of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depith Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITIOW DESTRUCTION Irl [No septic system permitted it public sewer is � available within 200 feet.1 Installation will serve: Residence �"'f Commercial Other �+Q11'1A1 41�y,4 TSR Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: C L A Water table depth SEPTIC TANK ❑ Type/Mfg _ �cf- Capacity 7-Ag V No. Compartments i PKG, TREATMENT PLT. 0Method of Disposal } Distance to nearest:, Weft*-_F �bIA Foundation ,_1 7, - - Property Lina LEACHING LINE No: & Length of lines _-Z y �� _ Total length/size FILTER BED n Distance to nearest: Well��A Foundation _ 2,e Property Line SEEPAGE PITS l Depth 2.0 __Size Number Z ' SUMPS LI DAI/ � O Distance to nearest', Wali- — foundation Z�___ Property Line DISPOSAL PONDS ❑ 'IN `1 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 I' Home owner or licensed agents signature certifies the following: "I canny 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 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 applicant must call for all required inspections. Complete drawing on reverse side. ` Signed X Title: Date: r FOR DEPARTMENT USE ONLY [cation Accepted by ' Date Area PI r Grout Inspection b Dat 2 I -f- Final Inspection by Dat Additional Comments: - Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES I 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED 9Y DATE PERMIT'NO. EH 13.24IREV,rin5) r! UC' O `^'11 I-' �" [ A-13`✓ 57_—. '3 '// EH 14.26