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APPLICATION FOR PERIdIT �E SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION fa 445 N SAN JOAQUIN, PHONE (209)468-3420 J U L 2 4 1892 P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH PERM T' EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES nxR ,.f (Complete in Triplicate) Application is hereby made.to Bea"Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3 �3 S. -� lSMf�1J ��• City �- Lot Size/Acreage 14c_ ± Owner's Name s.lg71' �IgICF'� -_Z Address �� Phon 83Z- � _ r�Q 3G zo .Cl =rr-)U rf �9 u Contractor s uM �• Address • e0�►�o 611• 1'43? License No. �OF0 Phone• 1,2/ 7y -OF WELL/PUMP: NEW WELL D WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑.- .. SYSTEM REPAIR 14, OTHER ❑ Monitoring Well ❑ '01STANCE-TO-NEAREST: 'SEPTIC�fANK' '=""""`_=SEWEA-LIN ESDISPOSAL-FL-0—PROP:-L-INE------- -� FOUNDATION ` TAGRICULTURE WELL OTHER WELL PITS/SUMPS �. ' INTENDED USE• TYPE OF WELL `.PROBLEM AREA CONSTRUCTION SPECIFICATIONS I-] Industrial r O Open Bottom " C3 Manteca Dia. of Well Excavation Dia. of Well Casing p fl'Domestic/Private Cl Gravel Pack L7 Tracy W Type of Casing_ Specifications— , ['1 Public f-1 Other fl Delta Depth of Grout Seal Type of Grout !l I Irrigation —.Approxi, Depth I I Eastern Surface Seal Installed by - Repair,Work Done Type of Pum{p 4Q- J3_ H.P. 1�� . Stats Work Dona a Well Destruction ❑ Well Diameter' Sealing tKaterial i Depth- i� ' Depth ? Tiller Material i4 Depth s. TYPE Of SEPTIC WORK:j NEW INSTALLATION1'I REPAIR/ADDtTION i I DESTRUCTION f I INo septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence Cori%mercl'al— Other ,/ r .j: ATM `, C Number of living units: Number of bedrooms t s ��+. Character of twN to'*depth of 3 feet: Wata SEPTIC TANK ❑ Type/Mfp Capacity No.�Compartments PKG. TREATMENT PLT.0,' ;� " �.: Meth"101f Wspiit � -„'Distance to nearest: Well .Foundation Property r7�e Ing' A!"'�'li NTV - { i I 4 T1; =r_l�V1,CFS �� L HEAL NMEIVITA LEACHING LINE Cl No. 14 Length of lines _ Total iength\a[t FILTER SED ❑ Distance to nearest: Well Foundation Property Line i � r SUMPS- , LI Distance t neaiast:`` Well Foundation Number SEEPAGE PITS i I Depth Sire __ - j �Js - - _ ..�.. � '�� .Propsity Lina y DISPOSAL PONDS ❑ f 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` t" . N 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 fogowi wrtify the in the performance of the work for which this permit is issued,.l shall employ persons subject to workman's compensa- tion laws of C 'ornia." The applican r ui inspections. Complete drawing on reverse side. 4 Signed Title: `� Date: ` y X FOR-DEPARTMENT USE ONLY Application Accepted by /i ` Date Ares Pit or Grout Inspection by v Date Final Inspection by Date Additional Comments; r Applicant - Return all copies to: � San Joaquin County Public Health Services Environmental Health Permit-/Service.s f ' 445 N San Joaquin, P O Box 2609,fStkn; CA 85201 y)/N/�FE /AMOUNT DUE AMOUNT REMITTED CASH � +RECEIVEbiBY DATE' PERMIT NO EH 13-24 tREV.I/As) Tit T S EH s3-E3 `