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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON,- CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 nude in compliance with San Joaquin County ordinance No. 549 and 1862 and the Rules cad Regulations of San Joaquin County Public Health Services. Job Address W- AeA$ 9&4. City ^."'.."' Lot Sirea8 Owner's Name � �/4^r, aNF_ Address yDf ll)• ls �'`4' Phone Contractor AX#i $ Address fjo. 2G License r _'G Phone ids TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION O Out Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER,.Q Mpnitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SU!JPS_i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia.of Well Casing * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ' Cl Other fl Doha Depth of Grout Seal Ty dr of Grout I I irrigation ,_,..Appy&. Depth I I Eastern Surface Saul Installed by Repair Work Done 0 Type of Pump, H.P. State Work Done_ Well Sealing Material i Depth peetruction O Well Oiertater, ., __YY Depth_ Tiller Material i Depth 'r TYPE OF SEPTIC WORK: NEW INSTALLATION I I ADDITION I DESTRUCTION IJ-010 septic system Permitted if public sewer a % available within 200 feet.) Installation will serve: Residence Commercial_ tfnat F Number of living)units; _. Number o Character of soil to•depth of 2 feeC `f > x - !Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O -- 1, Method of Dill Distance to nearest: Well fit? -Foundation s Prowty Line {'r LEACHING LINE filo:8 Length of lass Total length/ zi a �. --- fir -- FILTER BED O Distance to nearest: Well Foundation l0 +_-4k wny Line SEEPAGE PITS I I Depth 's Size Number T_ SUMPSLi Distance to nearest: we Foundation �� ~ o� Line DISPOSAL PONDS O I hereby certify that 1 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 oenifies the following: "I certify that in the performance of the work for v"L h this permit is issued, 1 shah not employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's;hidng or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this.permit is issued,I shalt employ penons-subject to workman's compense- don laws of California." The applicant mustcall for all requ ed inewtions. Complete drawing on revetee side. Signed X.,,s, jon, Title: Dans: �•!r _r DEPARTMENT USE ONLY Slf 113 Application Accepted byDate Area c2l Pit or Grout Irapection by Date Final Inspection by` Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O-Box 2009, Stkn, CA 95201 FEE AMOUNT WE AMOUNT RfiMf"EO RECEIVED BY OATE PERMIT'NO. INFO � / / p p /�� p q� . EN 13}24IREV.r/Ksl sS� �( �/ OZ� l0 t7 39 L7Z� Z T 93 5B—D EH N•2E