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b APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION le-2' z7U13 /J6 r 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 �-y ir1�r9�.5a L�tA IYYI PERMIT EXPIRES 1 YE FRQM 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 sypgication in made in compliance with San Joaquin County Ordinance No. 514J no �$� and the Rules and Regulations of San Joaquin County Public Health Services. PnJ zs w Z_- a-�r�- C> ! g S Job Address Q=* &10 -__--- --- City^�!'Lf}t:.y Lot Size/Acreage ACA-e f Owner's Name 1-uC{L'f"�' J�i�y Address CIW3 L e_Zdr_ — MNZ/9Phone a ,X45i Qui rr�rz�z.' Conttacto k- k4el f- dress Z8 M*LTLe S1:License No.l]l � Phane TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ t of Service We?1 171 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERY ❑ k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. enuo FOUNDATION AGRICULTURE WELL OTHER WELL `ft�f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l4.ZOl i N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ SpesWeetion& VI Public El Other n Delta Depth of Grout Seal 7� L4m%4 �ft�l, ZeUr I I Irrigation ,T:-.Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth ` L Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/AOOITiON I I DESTRUCTION I t JNo septic system permitted it public sewer is ` available within 200 feet.M installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. 6 Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI 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, end f rules and regulations of the San Joaquin County 4 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, 1 shell not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature.r� 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 compensa- tion laws of California." The applicant s all for all r inspections. Complete drawing on reverse side. Signed t Title: Date: FO D ARTMENT USE ONLY Application Accepted byDate Area j Pit or Grout Inspection by Date Final Inspection b Date Additional Comments Applicant - Return all copies to: San Jo uin County Public Health Services - Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK. RECEIVED BY DATE PERMtT'NO. c Q a � • CX31T T_ Ell 12.2 (REV.li�6l C'� 1220 I -WE � EN 11.2E .. !� P H