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l - TT APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �� ! -2- � ENVIRONMENTAL HEALTH DIVISION -r. �¢� P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EMIRES 1 YEAR iRQ9 DATE ISSUED ;�►� I."� (Complete in Triplicate) Application is hereby made to San Joaquin County for n permit to construct and/or install the vork herein described. This application is made in cmwliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address .2'7 2a 1 Al, QLel,ELLQ P b City ! Lot' Size/Acreage Owner's Name P&T;' P SNF- 6 0/W E Addre stS� _ [,K'Gentles BLY�. ,�t,N G Phone Contrattor waeAddress .1'�1�EL� r- � License No. 2%I��-yam Phone r�5?i TYPE OF WELL/PUMP: NEW WELL ❑ WELLREPLACEMENT-1-1- DESTRUCTION CI Out or Service Well 0 PUMP INSTALLATION ❑ 1 SYSTEM REPAik.C1� _. OTHER O Monitoring Well-t(.1 DISTANCE TO NEAREST: SEPTIC TANK- 5EWER""LINES DISPOSALr-16, PROP. UNE �.S FOUNDATION AGRICULTURE WELL OTHER WELL-1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f71 Industrial ❑ Open Botta ❑ Manteca= Dia: of Well Excavation Dia. of Weil Casing U Domestic/Private .. ❑ Gravel Pack El Tracy Type of Casing "Specifications M Public Ia,flther ❑ Delta Depth of Grout Seal r Type of Grout Cl Irrigation Approx. Depth ❑ EBstern S ace Seal Installed by Repair Work Done-- v Type of Pump H,P, State Work Done _ Well Destruction D Well Diameter Sealing Material a Depth i s: ... , +" Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION L-1 DESTRUCTION 0 (No septic system permitted if public sewer is available Within 200 feet) Installat pn,will serve: �Residence `� Commercial— Other 19141W , Number ofAliving units:-+`�/Number of bedrooms " Character of soil to a depth of 3`feel: t� _ Water table depth 67 SEPTIC TANK" Type/Mfg _-- _ L. Capacity- 125- No. Compartments Y PKG. TREATMENT PLT, Cl Method of Disposal', Distance to nearest: Well-Zag-71" Foundation +V Property Line _,J_LQe'2L I� LEACHING LINE No. 8 Length-.of lines Total length/sire ' V FILTER BED n Distance to nearest:. Well /e2 C f Foundation - �� Property Line SAO SEEPAGE PITS ,YQ Depth ZSr Siie. �_�r Number SUMPS Ll Distance to nearest: well 'IJ f- Foundation 461 _ Property Line 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 ruins and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following; "I cartify`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 of 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 compansa- tion laws of California." -�--- , The applicant must call for all required inssppe�cttions�Co plete drawing on reverse side. Signed G'A' G Title• ". Date: FOR DEPARTMENT USE ONLY C� i Application Accepted by ` Data 1-2--1 j`�_ Area 2-j Pit or Grout Inspection by _ Date Final Inspection by J Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 � I lFEE AMOUNT DUE AMOUNT REMITTED K RECEiVEO 8Y DATE PE 1mrr'JNO. . tiH1 .241REV.tin61 ( 11�. vO � � lr00 EH.44.1a