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s APPLICATION ff SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 . P 0 BOX 2009, STOCKTON, CA 95201 PERMIT F. IRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application to hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is merle 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 —_ �.�dC] 1'a __'2LG, CityLot Size/Acreage 51 Owner's Name __ 1C_4NJ-' Me ( _ Address 4:t_ Phone - 7 Contractor Address � License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 111 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _-AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE_ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industriali- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing Cl Domestic./Private ❑ Gravel Pack L1 Tracy Type of Casing_ Specifications I'1 Public i-1 Other -n Delta' ` Depth of Grout Seal Type of Grout I I Irrigation r Approx. Depth I 1 Eastern Surface teal Installed by Repair Work.Done L7 Type of Pump j H.P. State Work Done Well Destruction —❑ Well Diameter Sealing Material & Depth C� Depth Fillerfateriall 6 Depth TYPE OF SEf PTIC WORK: i NEW INSTALLATIONS REPAIR/ADDITION 11' DESTRUCTION I I (No septic system permitted if public sewer is �— available within 200 feet.) Installation will serve: R)ssidence-Y--- Commercial ' Other. q Number ofliving units: _L1_ Number of be rooms EE Character hf sail to a dejth of 3 feet: �Pt"T tiA-V ` I..� �� —Water table depth r SEPTIC TANKS -WL Type/Mfg CapacityIP42 92` No. CompartmentsPKG. TREATMENT PLT.❑ 4 1 '�. 2Method of Dispos Distance to nearest: Well \�Founda1ion y Property Line f 5 �a LEACHING LINE 451'- No. & Length of tines 0 t " Total length/size— FILTER BED ❑ Distance to clearest. Well �— FoundProperty Line SEEPAGE PITS Pt- Depth `aJ'`^ Size afo rA v Number SUMPS LI Distance to nearest: Well --Adw-2 Foundation Property Line_(OV' P05 DISPOSAL PONOS ❑ 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 San Joaquin County r 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 arty 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: "kenify 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." C The applicantmust II or all requi d in pections. Complete drawing. reverse side, Signed Xl r-' Title:" Date: _ <--- !l F R EPARTMENT USE ONLY �"� Application Accepted by Date '' rea t32- r t it r Gout Inspection by Date ? Final Inspection by Date / a - " Additional Comments: i 16iW _Applicant - Return all copies to: San Joaquin County Public Health Services "EnvironmenCal-Healtti-Permit/Services' " 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMiT'N0. INFO CASH �y`q, CF� « H1 -24INEV.iix51 1 c� O �}�f �/` �� y—�f'3 � EH 14.26 t