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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR F'ROd DATE ISSUND (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. Job Address 2,4-3 _i �A0z"S7 'e-41` P- - City Lot Size Acreage Owner's Name 13ECA- D�/ Address i%%41 /1,/- f � .r?t`i� ,c ,c•� Phone Contractor f�a rl) 4,�-7. 416y_0 Address 1 A/a� r�zeT' License No. 5�> 'i7a Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 0 DESTRUCTION ❑ Out of storingService Well [I PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well �� "J 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 ' C] Industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1'1 Other O Delta Depth of Grout Seal Type of Grout 0 Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Wgll Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION JX REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial-_ Other &e,4_5AI Number of living units: Number of bedrooms Character of &oil to a depth of 3 feet: S A Ali.>Y C 4-A Water table depth SEPTIC TANK Jr Type/Mfg C C _ PV_L- Capacity f x nD No. Compartments .- PKG. TREATMENT PLT,Q Method of Disposal f Distance to nearest: Well def Foundation 4i' Property Line _ LEACHING LINE QV'No. & Length of lines ° Total length/size ` FILTER BED 0 Distance to nearest: Well 1-ae7-t' Foundation _fes r Property Line Sp` SEEPAGE PITS We5 Depth Size �'Z 7- ` Number r SUMPS Distance to nearest: Well I Foundation Property Line ` J DISPOSAL PONDS ❑ 1 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 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 inspgctio/ns. Complete drawing on reverse side. Signed X_ -��--��f � fb'�7-7ioTitle: `�0— Date: FOR DEPARTMENT USE ONLY Appl' tion Accepted by Date! U 'r7! Area or rout 1 tion by Date —Lt211J1 Final Inspection by Additional Comments: — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE OUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO *CASH/ 6 . EN 13•24IREV.1/"5) t Q }. L r O U EH 11.2111