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I .a , r ,• APPLICATION FOR PER9I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �-ll6D P 0 BOX 2009, STOCKTON, CA 95201 70 V 4�4 C�- (209) 468-3447 PER.YIJ EXPIRES 1 YEAR PRQM DATE ISSUED �� (Complete in Triplicate} A licatio/la hereb�trte[3e to Seas pp y qu 4.tinty for a permit to construct and/or install the cork 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. 47 Lot Size/Acre e Job Address City aaF, . P`e /174UG Owner's Name Address iWOZ Phone Contractor ,� Address 2Y_G O- e�A' 7ti?_ License No. F1 Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 177 DESTRUCTION ❑ Out of Service Well ❑ ^J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER).- nitoring Well �� 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - r FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS _ 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public i'l Other 0 Delta Depth of Grout Seal Tvri of Gouts GI Irrigation Approx. Depth D Eastern Surface Saul Installed by t4Z c-4 Repair Work Done D Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth i TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION ZI (No septic system permitted if public sewer is available within 200 last.) Installation will serve: Residence Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line y J SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line I f DISPOSAL PONDS ❑ 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 I 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 subcontracting signature certifies the following: "I certify th in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif is " The applicant s o al i pections. Complete drawing Signed Title: o �r ~ R Data: Cza/ k FO DEPARTMENT USE ON Application Accepted by Data Area 1_S Pit or Grout Inspection by j Date. (~ rf`R Final In:pection b Data C Additional Comments: (� Applicant - Return all copies to: SAN JOAQUIN COUNTY PU LIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT pt1�-Eye AMOUNT REMITTED CASH RECEIVED BY DATE �PyERMIT N0. + EH 13-24 IRfV.1/w 51 t� /4 �I Q]J c? EH 14.25 's