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APPLICATION FOR PERIL[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT_EXPIRES 1 YEAR FROM- DATE_ I SIIED A (Complete in Triplicate) Application is hereby made to Sen Joaquin County for a permit to construct and/or-install the work herein described. This application is sonde in cosplia.nce with San Joaquin County Ordinance No.. 549 and 1862 and the Rules and Regulations of San , Joaquin County Public Health Services: a Job Address g g/o/ C07,7_AL &a-e sibl c�- City T- Lot Size/Acreage Owner's Name I)AV;d ✓ Address Phone �•s Contractor O SAN Address 4Q1 OA License No.y �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 14onitoring Well CJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` t DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - C1 Industrial_ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing y f:1 Domestic/Private n Gravel Peck ❑ Tracy Type of Casing_ Specifications 0 t I'i Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by 1 Repair Work Done U Type of Pump H.P. State Work Done � Well Destruction ❑ Well Diameter Sealing Material 4-Depth � 1 a Depth !'filler Material fi Depth M TYPE OF SEPTIC WORK: NEW INSTALLATION V1 REPAIRIADDITION ( I DESTRUCTION i-1 iNo septic system permitted if public sewer is }" available within 200 feet) „ Installation will serve: Residence Commercial Other 1 Number of living units: Number of bedrooms 3 `' ,i% Character of soil to a depth of 3 feet..-j1dek1% _= Water table depth SEPTIC TANK 0 Type/Mfg A” C-Ald Alf 4 a Capacity 'rl 0(7 No. Compartments � PKG. TREATMENT PLT.C) _ I Method of Disposal Distance to nearest: Well Foundation �� Property Line -st) BLEACHING LINE Col No, 3 Length of lines a "' �� Total length/size .FILTER BED''. . O D' t n rte I .�� Y Foundation /-� Property Line I-r F' t ,7e, SEEPAGE PITS 11 Depth(/ D Sire / Number ^ SUMPS e kf Distance to nearest: Well !eO r-7Foundation 10-0 r Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work-wiil bs done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County i .�` �-v ,„i - 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;66come subject to workman's compensation laws of-California." Contractor's hiring or sub-contracting signature certifies the folowing: "I certify that in the performance of the work for which this permit is isaueed, I shall employ persons subject to workman's compensa- .J tion laws of California." (J The applicant mu 'call for ail required inspections. Complete drawing on reverse side. Signed ,.. Title: Date: 'p-Z-72 FOR DEPARTMENT USE ONLY Application Accepted by Date Z�6 Pit or Grout Inspection by to Final Inspection by Date e/ �Z Additional Comments: _ o Applicant - Return all copies to: San Joaquin County Public Health Services ' Environmental Health Permit/Services 445 N San Joaquin, P 0 Hog 2009, Stkn, CA 95201 FEE INFO 'AMOUNT DUE AMOUNT/REWTTEEG K ,RECEIVED BY i DATE + PERMIT'NO,PIC V . EH13. IRFN.fie51 /� L� q ,1l 7 2— �rS EH t41•ffi