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APPLICATION FOR PERMIT SAN"4wOAQUIN COUNTY PUBLIC HEALTHY. RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ceEaiiiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. M t�- Job Address —f 31 So U TN CC-NTc-k S r ABY City TT$CKT+d.J Lot Si'ze/Acreage N�fi SQ I r Owner's Name(f*eval'i V 1�t 14 r Address Pro, & 7��, S�}� //�+A0 ,C-A Phone S/Q L '75-00 Contractor aREGG >ZICLrIJy Address ?0 ok/ hRTIaE C�ic€h e No � 7�6� Phone.7� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n OESTRUCTI Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEER Monitoring Well O SOiL BORlN�S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP P. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial O Open Bottom ❑ Manteca Dia. of We*Excavation Dia. of Well Casing —61 1A n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casinng Specifications Il Public n Other n Delta Depth of Grout Seal a Type of Grout Ne,+rce1.1ey I 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by &R C76 RlLC/.V Repair Work Done U Type of Pump H.P. State Work Done _ N IA Well Destruction ❑ Well Diameter N Sealing terial i Depth UT--> 'z�4.5 BGS Depth ^' 5 Fr filler Material ti Depth nd A TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of toll to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. f4 Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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, state 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 workmen's compensation laws of California." Contractor's hiring or 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed x _T— /A- ./\i (l-r=)L--- Title: 4,rS0c1,+TV' Ci EO LC 4/S T Data: -j rLWt^ AA1ADa'-1' FOR EPARTMENT USE ONLY m V Application Accepted by i Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT NO. INFO CASN EH13-74 MEV.r i A 5) ✓� �OS �,( '�✓ EH 14.76 `�K 1