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APPLICATION FOR PERMIT 3� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION k 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 (PERMIT E%PIRES I YEAR FROM DATE ISSUED i r (Complete in Triplicate) i L 3Y3. E- .c�,t..csmc�r2.� , r�n� Application is hereby made to San Joaquin County for a permit to construct and/or sesta the work herein described. This �J application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San LT' Joaquin County Public Health Services. BAST O F 0UAJCr'W Job AddressCOM 3T-0 CK P,-,D O Ci-JeA.J (zoo, ,s City lAt Size/Acreage Name L TI� CVtOAS Address f kb�-� �4 R L1`09v, 5? Phone U Owner's N Lf"-0 E F 2c.AU'�T g�'/ o Contractor h1 Address License No-��1'73 -Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION 2'� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well i\ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (f i t ti FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industriai ,eO Open Bottom ❑ Manteca Dia. of Well Excavation Ole. of Well Casing Ll Domestic/Private ..❑ Gravel Pack 11 Tracy Type of Casing_ Specifications [1 Public 1-1'Other n Delta Depth of Grout Seal Type o1 Grout1 �I ""frigation- ApproxDepth I I Eastern Surface Seal Installed by (Repair Work'Done U Typeof'Pump 5V is H.P. State Work Done, -AISk �f Wei-Destruction ❑ Well Diameter Sealing Material i Depth _ __ r�L. - 11CI CKIS7,/MSC% •-.T-••,-_F ,� Depth IM _R Miler Material. i Depth h / ITl N I I DESTRUCTION l I iNo septic system permitted it public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION 11' REPAIR ADD O P _ —_-- _. ., , availabli within 2001e4t:). Installation will serve: Residence—I Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK 0 Type/MfgCapacity_ No. Compartments C i� PKG. TREATMENT PLT.0 I Method of Disposal P Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED C1 Distance,`�`to nearest: Well Foundation Properly Line ^ ' SEEPAGE PITS 11 Depth 0 -Size Number t SUMPS LI Dismncito nearest: Well Foundation Property Line DISPOSAL PONDS O ' 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 k employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 Uwe of California." The applicant must coli for all required inapgctions. C mplete drawing on re n aid _ Signed i Title: Dater Z - I0 OIkLY I ►�. ✓ Application Accepted by rAA" �4 Data Area�— — ' SIKI Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ' Applicant — Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Servicee 445 N San Joaquin, P O Box 2009, Stkn, CA 98201 IF EE 0 AMOUNT DUE 1I AMOUNT REMITTED CASH RECEIVED BY 4D�ATE Q PERMIT'NO. {{ . EM 13-74 t11EV.1/RZ,I �I ✓ , � � - �d / •✓"0 v } EH 14-25 `I 4 t1 II