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li II �f APPLICATION FOR PERMIT 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION li P 0 BOX 2009, STOCSTON, CA 95201 , ; i, (209) 468-3447 j pIt>I�TT E$PIRES 1 YEAR VRQX DATFs ISSUE) (Complete in Triplicate) i Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This 1. 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. Job Address C26 1 70 Ott) City a Lot Site/Acreage IIG Owner's Name Address 5sj / / Phone � a Contractor i.5S AMA9dr�S5 3� l&A - L/Akow�ense No. 4LL V Z Phone�� TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT C❑ DESTRUCTION ❑ Out of Service Well 0 i PUMP.INSTALLATION�K_ SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 4 AGRICULTURE WELL OTHER WELL PITS/SUMPS - 1 TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s. € In ustrial Open Bottom 0 Manteca Dia. of Well Excavation / Z— Dia. of Well Casing f mestic/Private C1 Gravel Pack ❑ Tracy Type of Casing S Specifications Public . Cl Otfi.. © Datta Depth of Grout Seal �0 -- Type of Grout G tfngation ?111Q.Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P, State Work Done Well Destruction O Well Diameter Sealing Materialk Depth Depth 1l Filler,Material i Depth TYPE OF SEPTIC WORK; NEW:INSTALLATION i t REPAIRIAODITION 0 DESTRUCTION CI INo septic system permitted if public sewer is f T , available within 200 feat) V Installation will serve: Residence Commercial— Other O A Number of living units: — 11 Number of bedrooms ,Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK 0 Typi/Mig Capacity No. Compartments ,. PKG. TREATMENT PLT,0 Method of Disposal i Distance to nearest: Well Foundation Property Line: LEACHING LINE 0 No:,`& Length of lines Total length/site FILTER BED ED Distance to nearest. Walt— Foundation Property Line II. SEEPAGE PITS 11 Depth Size Number k SUMPS Li Distance to nearest: Well Foundation wl. Property Line DISPOSAL PONDS ❑ JI 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 t 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 mannet as to become subject to workman's compensation taws 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; I shall employ persons subject to workman's compensa- tion laws of.California." The applicant must call for all r II d inspections. Complete drawing on reverse side. I a' Signed X Title: Date: t�~ � �� •— , F II ENT USE ONLY I� I Application Accepted by Date a-- v�S _ _. Area 12 � r Pit or6r Inspection by ate Final Inspection' by Date 2. } Itl: S Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1. ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES i 995 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 ; i FEE AMOUNT DUE AMOUNT REMITTED CK 2 RECEIVED BY DATE PERMIT NO. INf CASH I Z EH13-24WEV.I/M51 `r©� 3 -ov IcpO a 1 �� - -CI Q1 -6ZZ7 EH ,�. .. I -O3z-$ P