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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERRL' EXPIRES 1 YEAR FRQki_] AIE ISSUM (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct end/or install the Work herein described. This application is trade in compliance with Sart Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Htalth Services. d � 5 G//'l7rltE,Cb' Cit 5 Y9t� Lot Size/Acreage Job Address Y Owner's Name /ZA/G n rVAIAI Address d O Z- Phone 9.3 Contractor_.FL-aYr7_ _E. tdaaD_ Address 7 N DE License No, Yy--)L-74. Phone 44L 29-71 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C-1 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM AIR L7 OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST; SEPTIC TANK EWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION A ICULTURE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A A 0NSTRUCTION SPECIFICATIONS f-} Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private- ❑ Gravel Pack n Tracy Type of Casing Specifications 111 Public I'll Other (jDelt epth of Grout Seal Type of Grout CI irrigation �.Apprpx, Depth ❑ stern S ace Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done _ �1 Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material Ir Depth TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION Cl DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence '� Commercial— /Other Number of living units: Number of bedrooms 4= . Character of soil to a de�p/th of 3 feet: . - _C_ A X „„ -„, _,_.,,,, Water table depth SEPT-IC-TANK [O Type/Mfo Y-L Capacity /&00 No. Compartments PKG, TREATMENT PLT.`L��-fit T� r Method of Disposal Distance to nearest:.- -Well Q 1� Foundation�O Property Line 449 ` LEACHING LINE No. & Length of lines 4 4 Tota"length/si:a /700 t� FILTER BED 1.1 Distance to nearest: Wall /„�O Foundation __Z4_V_' Property SEEPAGE PITS l Depth Size Number 3 SUMPS LI Distance to nearest: Well J-019 Foundation �a f Property Line �O 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 Sen Joaquin County Home owner or licensed agent's signature certifies the following: ',e tify 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 workmir's compensation laws of California.” Contractor's hiring of 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 Iowa of California." The applicant must call for all required inspecti ns. Complete drawing on reverse side. Signed X e Title, Date: - .Jd L4- 4 a FOR DEPARTMENT USE ONLY rlicavon Accepted by Date 10- a Area A311� _1__ • ca Pit or Grout Inspectio Date(0 z Final Inspection b K ^ Date( Additional dd tional Comments: Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 INFO AV FEE AMOUNT DUE AMT REMITTEO �K H AECEIVEO BY DATE PERM17'No, . Em 13.24IREV.I/A51 , .(1 3� VS