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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$--3420 P O 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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. n !f Job Address _f U + 2 G A-Jr 1"� ti City M A VI 1 CC$4 Lot Si ze/Acreage .-7 k+e r lel Owner's Name 14C-r t ra-SA ;fit-ffdte�Address 1,4 O fZ CYEs-rIPhone 32 2. 6 6 1 Contractor 5 'Z.L_E. Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Cl + _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ 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 C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17.1 Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing_ Specifications I') Public fl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by ao Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION tat" DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: ' Residence Commercial_ Other Number of living'unlis: _1_ Number of bedrooms Character of soli to a depth of 3 feet: . Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Cl Method of Di Vosal 10`iSer 13 Q4P Distance to nearest: Well Foundation _*100' Property Lits i a� LEACHING LINE C1 NO.4 Length of lines Total length/site' FILTER BED r OR"Diatance to nearest: r Well Foundation Foundation C Prop Line 20 3 X 2 c.j - �E-!C �-�r .fit o ve SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation 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 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 hiiing=or.sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." _ F The applicsst tail for alt requir inspections. Complete drawing on//reverse side Signed X / Z Title: ! yp s _. _ Date: 2-, 17 ' 3 _ DEP&OMENT SE ONLY Application Accepted to Date Ar Pit or Grout Inspection by Date Final InspectionDat Additional Comments: ,4&_ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Boa 2009, Stkn, CA 95201 IF Q AMOUNT DUE AMOUN/T�REMITTED CAS RECEIVED BY ATE PERM17 N0, . EH 13.24 1lItY.r e 51 FH 14-36