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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 NGV 993 (209) 468-3447 PERMIT EXPIRES I MAR SROM 12ATE ISSUEDE. I'vVl2Ji'vi1 E!\!CA,L Ht/,LTH (Complete in Triplicate) F` I ;�,',Ii1SLR1�ICf:S Application is hereby mala to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in CcWliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San Joaquin County Public Health Services. PA) l� Q,� Job Address I1�F`"— :�13 ar= RA 604t I 1 c� City � 1Zr__K-TC+,) Lot Size/Acreage 1&,44 Owner's NamA_A2_?-44C,1.-radN +�A r�iA�G lZS Addrass LLfL7 -�AfJ r3� +A S T� j�c�rx ror.� Phons6"'_ 02_ Contracts . _ ar 6J._(2 W4&Z: Address�23 RIo9,7-j?D hlU)2&S T u License No.4rlo _o Phoned L� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER 8 SMonitoring ort to ingWelll ❑. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z00 DISPOSAL FLD W—ZA PROP. LINE �, L4' s FOUNDATION 4Y_A_ AGRICULTURE WELL/YL OTHER WELL_J PITS/SUMPS 16ZA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0,Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public )4',,O `ther ❑ Delta Depth of Grout Seal eoel L�l4-05' Type of Grout " CJ Imostion 8Q, �� Approx. Depth D Eastern Surface Soul Installed by Repair Work Done 0 Type of Pump H.P. State Work Done . Will Destruction ❑ Welt Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 REPAIR/ADDITION Cf DESTRUCTION G (No septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence_.. Comme(ciat_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/sire FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line d DISPOSAL PONDS O I hereby cenity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the Sen Joaquin County Home owner or licensed agent's signature canities the following: "I cenity that in the perlormance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following. 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• tlon laws of California.' The applicani'mjistj a for quired I speclions. Complete drawing on reverse side. Signed Title: 150 -Y-rr:a- C!f[ 1. tANT _ Date: l�ar1, 5l 1 pry FOR DEPARTMENT USE ONLY Application Acca ted byDate Area 3 Pit or Grout Inspection by Date Final Inspection by ,.._ Data U 7 Additional Comments: Applicant - Return all copies to: SAX JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAH JOAQUIN, P 0 BOK 2000, STOCKTON, CA 85202 FEE AMOUNT DUE CASH AMOUNT REMiTTEO RECEIVED BY DATE PERM17'NO. EH 14.24IREV.IiMst grijo H 7.4-26a ioaq �r 1 100N.211 E