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APPLICATION q SAN JOAQU IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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. Job Address _ ISlola Z �', S7—/EA/4 GLJL R D City -_SL'41_yA1 Lot Size/ creage Owner's Name P', 04 7—,&A/ Address /S'_-L046 S. 2__P_ Phone 1 Contractor IGLes 5/17 LdD+c7D A4zlzLicense No.�L�s�a-�Phone �1 TYPE OF WELL/PUMP: NEW - WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ Monitoring Well PUMP INSTALLATI SYSTEM REPAIR L7 OTHER ❑ L7 DISTANCE TO NEAREST: SEPTIC TANK *46S, DISPOSAL FLD. PROP. LINE FOUNDATION ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Ope t ante Dia. of Well Excavation Dia. of Well Casing FI Domestic/Private ❑ Gra" . •ack "t 0 Tracy fi Type of Casing_ Specifications t e; � I'I Public f-1 Other{ n Delta , VDepth of Grout Seal Type of Grout I I Irrigation _,Apex. De l I I Easter Surface Seui Installed by �F�. Repair Work Done 0 Type o}F,ump H;P. " State Work Done _ Well Destruction ❑ Well Diameter !'Sealing4* rial & Depth Depth I i # ' Filler "ial & Depth f TYPE OF SEPTIC WORK: NEW IN TALLA ON 1 i REPAIR/ADDIYI DESTRUCTION (No se rc system permi i is sewer is > availab within 200 feet.) Installation will serve: Resident r Co rrtsercial Other Number of living units: ber of,bedrooms Character of soil to a depth of 3 S/J.t/A e- Water table depth (� ` SEPTIC TANK ❑ Tyf►e/' F t 4 Capacity 12_00 No. Compartments 2 t:i;f PKC. TREATMENT PLT. ❑ Method of Disposal Dist nee t: Well ` �O0 undation_/40.1 Property Line /44W` LEACHING LINE LA 'No. & Length ri — O Total length/size FILTER BED ❑ Dist a to neaI : Well �CA7 oundation /40 _ Property Line Zew SEEPAGE PITS I`l D Size�'X/ Number SUMPS Dist to near Well oundation Property Line DISPOSAL PONDS ❑ I. n I hereby certify that I have prepar is-wpplication Qk the k will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Jo' in Coun Home owner or licensed agent's sigmIL re ca fa ng: "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 ome sub' workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that int 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 required inspections. Complete drawing on reverse side. Signed X ---- Title: &U22: Date: 92 OARTM USE ONLY Application Accepted by Date as Pit or Grout Inspection by Date Final Inspection by Oate�yC'/ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT MITTED CCAS A CEIVED BY CAT/E' PERNIMN0. • EN124iAEV.rin5l �� v EH 14-4-2e O