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t APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ° ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT .EXPIRES 1 YEAR kRQM DATE IS5= (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork. herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 end 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 � � )2,SaCrfS Job Address -53103 T� �` Sjg_fes t�tt,rwu �c 26 City cLcy_n Lot Size/Acreage N6t.X2`x_973,71 Owner's.Name �* '�t " - Address Q41 •firer FYe�r► S�u[Ic: rnM Phone 4rocl - 7SA3 t t Contractor"" Address "'i im License No. Phone TYPE OkWELL/PUMP" NEW WEL-L 0 t'-' a• t jWELL REPLAC H!€NT�,{•T_l DESTRUCTION ❑ Out of Service Neil ❑ PUMP INSTALLATION ❑ ij SYST. REPAIR`Q OTHER ❑ Monitoring Well �7 ' # DISTANCE TO NEAREST: SEPTIC TANK �qERfGINE.S :DISPOSAL FLp. PROP. LINE f f, FOUNDATION,..____._.._ , A C: L7l1,A ELL•�T 6iHER WELL PITS/SUMPS —� INTENDED USE TYPE OF WELL i PROBLEM AR °CONSTAUCTiON SPECIFICATIONS I f_l lndustial ❑ Open Bottom ! © Manteca Oia, of Well Excavation Dia. of Well Casing f U Domestic/Private Cl Gravel Pack 0 Tracy ,: �e of Casing " Specifications ' ❑ Public CI Other ❑ Do' el' De of Grout Seal '� Type of Grout..., 0 lirigalion _Approx. Depth aster 1 11 ISurf1c eal Installed by Repair Work Done 0 Type of Pump =t H.PI Staie Work Done _ } Well Destruction ❑ Well Diameter t i Seilii4Material i epth Depth Filler. Material i Depth V`] TYPE OF;SEPTIC WORK: NEW INSTALLATION —REP-A[Ki-ADDITION i=1 DESTRUCTION CI (No septic system permitted if public sewer i! available within 200 leet.1 I Installation will serve: Residence K Commercial_ Other Cj 5 Numbe1t of living units: s::Number of bedrooms .3 - i CfEaracfer of soil to a depth of 3 feet: ►r� Water table depth 5n t SEPTIC TANK Pr TV*/Mfg C2•M n — �• 'i�-• Capacity%4nO.a 9a I No. Compartments' 2- PKG� TREATMENT PLT. ❑ I Method of Disposal t.r Distance to nearest: Well r Z Foundation S Property Line 3- I� I LEACHING LINE (8l No. $ Length of tines 3 40,1 Total length/sire (20" I FILAR 86 135 Distance to nearest: well 125 Foundation 10 Property Line Zg s S SEEPAGE PITS N Depth 2S� Sire X ZS Number i SUMPS ; X Distance to nearest: Well 142-5 _ Foundation 14 2. Property Line DISPOSAL PONDS ❑ I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andQ 1 rules and regulations of the San Joaquin County { >�1 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 shill not employ any person in such manner as to become subject to workman's compensation laws of Calilornia." Contractor's hiring or sub-contracting signature s' �•= Certifies ttie fogowinp:�'l_csrtify that in the performance of the work iQfs�chrrJS�ttl�s_perrfi[t.1s issued, E shall employ parsons subject to workman's compansa• tion laws bf Calif The applkant must call for all required inspections, Complete drawing on reverse aide, 1 Signed lL _ 2'L''`.'J 'li �h`7C^c1 _� t �Titre: 'Ci�71� ii"/``ititw y Date: F gEPARTMENT USE ONLY Application Accepted-by, • i! "a •^t Dale 1 Area ` Pit oftt Grout;Inspection bye Date: Final Inspection by r` Data Additrional Comments: 1 Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i + ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 3 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 [!k MOUNT DUE MOUNT REMITTED CASH EJ`,� ECEIVEO�Y^r z . DATE PERMIT NO. EH 13-7{IPEv.ii (y. 0� � Ib--D 5 (o EN�1.2a 1