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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PA?�Q'TpjF P 0 BOX 2009, STOCKTON, CA 95201 Reci Ift PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 2 6 (Complete in Triplicate) SAN,/ tg'93 PUBLIC CAQUtrV C Application 1e hereby made,to San Joaquin County for a permit to construct and/or inotall the kw application is nade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules an��u .b ftn Joaquin County Public Health Services. L C^�,L �rN D►V! t�N Job Address 139 Sou' "Se' �-a�y . �ity :5khA14 Lot Size/Acreage Owner's Nome awroo e-, r �&" &. Address 2Y-Z LO. �a Oy.. krPhone ContractorJOJI TOIlCAddress /J I071Ql G�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well All 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 LI Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �« [-1 Domestic/Private O Gr vel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1-,Oehler ato«ufavrti� [l Delta Depth of Grout Seal D Typo of Grout r I I Irrigation pprox. Depth I I Eastern Surface Seal Installed by Repair Work Done U Typo of Pump M'- H.P. AIA tato Work PQno '✓� Wolf Destruction O Woll Diameter Z filC=r Sealing Raterial 6 Depth CeW, A, 30)¢, Dopth 411;0 - Filler Material 6 Depth a _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will servo: Rosidenco_ Commercial_ Other —1J Number of living units: Number of bedrooms Character of aoN to a depth of 3 foot: Water tablo dapth SEPTIC TANK O Typo/Mf Capacity No. Comportmonts PKG. TREATMENT PLT. Method of Disposal Distance to nearest: Well Foundation Property Lino n LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED oundation Property Lino 1 SEEPAGE PITS I I Depth Size SUMPS F=rost: Well Foundation Property Lino NDS ❑ 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 Son Joaquin County Homo owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 cortifias the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ porcons subject to workman's componss- tion Iowa of California." The a a call for 41 roqu' in c' drawing on reverse side. /p SigTitle: Date: ' FOR DEPARTMENT USE ONLY 3S. ApVon //�_�_ Accepted by ' ' 1 Date �� ' Area Pit or Grout Incpoction by Date Final Inspection by Date Add'nionol Comments: 0411`'#6 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 !INFO AMOUNT DUE AMOUNT REMITTED -pe TT RECEIVED BY R DATE:�� PERMQIT'NO. . EH 13-241RtV.i/A5) ,�� sq�'� L�Q ) � '3 1 L13.' EH 14.27 W! 01