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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P 0 BOX 2009, .STOCKTON, CA 95201 ERMIT EgPIRES 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 eosgrliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Service@. Job Address 91 RAVIAO;I-lyCity d¢& r' Lot Size/Acreage Owner's Name D Z/A Address Phone Contractor LA Address 49 >20 License NcrFll a62SQ Phon TYPE OF WELL/PUMP: NEW WELL C3WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ - r. PUMP INSTALLATION ❑; SYSTEM REPAIR p DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing Fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications T] Public Ill Other n Delta Depth of Grout Seal T r ype of Grout 41 I Irrigation Approx. Depth I I Eastern Surface Soul installed by i Repair Work Done U Type of Pump H.P. State Work Done_ i Well Destruction ❑ Well Diameter ..'Sealing Material ti Depth ! j 1 Depth "'T4 Filler Material i Depth t] ITYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR IADDITION i I 'DESTRUCTION I 1 se{No septic system- lNoavailable within 200permitted it public sewer Is Installation will serve: Residence�Commircial_ Other r Number of living units: 4 Number of bedrooms _ r Character of sag to a depth of 3 Peet: '�`� - n`- Water table depth SEPTIC TANK ❑ Type/Mfg `'` ' CapacityNo. Compartments PKG. TREATMENT PLT.Ll �� r r `,,Method of Disposal Distarici tonea-resi:. Welles Foundation Pr � operty.Line lS�,,,,/� LEACHING LINE No. b Length of lines A V29 OA:-- a ry-"Total length/size��t� FILTER BED - Cl Distance to ne rasi:"" Wail - - � Ltd_ Foundation Property Line: F SEEPAGE PITS Depth a�-l°"ay Sized/ Number - 4 SUMPS El Distance tonsinst:� 1VelI�y��v*:Foundation �� - -P DISPOSAL PONDS ❑ — roperty Line 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, rules and regulations of the San Joaquin Cougty _ Homs owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." i The applicant must call f� all r fired ins pctions. Complete drawing on reverse side. I t Sig S' ned Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by AP Date Area Pk or Grout Inspection by Date Final Inspection by Date � ;613 !Additional Comments: "c ffp� r1-61 Applicant - Return all copies to: San Joaquin County Public Health Services J 7,6-• ^ NP, - r. �, .�., _�.,,.Env.fironmen.tel,_Health�Permit/-Servtcea.,,_, ,w_ Gr. Sf6U�6'� ':� { 445 N.San Joaquin, P 0 Bax 2009, Stkn, CA 95201 FEE AMOUNT.DUE AMOUNT REMITTED`\ CK .4,' RECEIVED BY PATE PERMIT'Np. INFO O CASH Q � (,� �/� /} . EH t}211REV.fitl41 � ! i 1 7 � J�.S /�••L� � dfi FN t4-2tl f _! F� i.