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-"fta� .M. APPLICATION FOR PERMIT 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 EXPIRES 1 YEAR FROM DATE SII (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or insta]1 the vork herein described. This application is Inde in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _.I.1 -3� F'_ � SAY -!�/-�N� �'� _T City f Lot Size/Acreage Zoe- -Ft Owner's Name A-B%J Address Phone 7 - D ` Contractor i►=:fIY7 t',c,fCnrs i] Address 7 44 AbCE,rSEA4-- License No. Jy3_1.71 Phone `4- 1 9.7 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Gl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 \ Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public fl Other fl Delta Depth of Grout Seat Type of Grout t 1 I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth �y Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION IW REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial Other Number of Wng units: i Number of bedrooms \ Character of soq to a depth of 3 fast:_ a-4-A41 _ Water table depth SEPTIC TANK © Type/Mfg n F''-^ Capacity �t0 _ No. Compartments PKG. TREATMENT PLT.Cl { Property Line Method of Disposal Distance to nearest: Well Foundation r i LEACHING LINE No. & Length of lines _ Nortel length/size12-0 FILTER BED 0 Distance to nearest: Well Foundation - Property Line 2C1 SEEPAGE PITS I Depth 9— ± Size cl Number SUMPS L1 Distance to nearest: Weil Foundation -J-10 Property Line d 4'I DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and rules and regulations of the San Joaquin County 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 any 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:"1 certify 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." The applicant must call for all required inspections. Complete drawing on reverse side, Signed E Title: Date: 24!3 -`7Z DEPARTMENT USE ONLY Application Accepted by Date Z' a Pit or Grout Inspection by Date Final Inspectlon b l Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 H San Joaquin, P 0 Box 2008, Stkn, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT*NO. Ex 1}21(REV.IiF51 C, A f"16� f