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yam, APPLICATION FOR PERMIT SAN JOAQU IN COUNTY PUBLIC HEALTH ERV I CES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009? STOCKTON, CA 95201 PERMIT EXPIRES 1 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r / i r� f r-/( r• S/rt (.. I City 11 k1cit Lot Size/Acreage ��•yt'i' Job Address � t Owner's Name l•rtr'r'r, (. r> su 11 C.C. Address= (_ rtr(,rr,,J��rt,1l'I1 Sect, Contractor,)',/_'- A '/(.t r it St:_- 1t_NAddress roll l -N / t 3 �cLCCtt / � License No(7r /L Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 11 DESTRUCTION L-I Out of Service well O PUMP INSTALLATION O SYSTEM REPAIR O �� <<i._ OTHER Sk Monitoring well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -5 t' I'7 DISPOSAL FLO. S r r / P�i�P� LI(lE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private Ll Gravel Pack O Tracy Type of Casing_._ Specifications 11 Public (-1 Other 1-1 Delta Depth of Grout Seal YS- j-T Type of Grout 1\1 C- 11 =11 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by t� Repair Work Done L1 Type of Pump H.P. _ State Work Done Well Destruction O Well Diameter •rs✓ Sealing Material A Depth /iv.r m Depth 2S r Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation �.� tcppe� Line LEACHING LINE O No. b Length of linea FILTER BED ❑ Distance to nearest: Well Foundation - froMIyft�Line SAN 'U114 Gt SEEPAGE PITS 11 Depth Size pU�L1 1,049pi(1!v rY pV PFI IE:.r SUMPS LI Distance to nearest: Well Founded UlI' jf'Ao qty Lms DISPOSAL PONDS O ,r,l/)y (fir'( I 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 cartifies 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 ,'�•, ;/' ' Title: A5`s c 1'r G r r �,t c Date: FOR DEPARTMENT USE ONLY rvo Application Accepted by V Date �` Area Pit or Grout Inspection by�j'� Date Final Inspection by Date Additional Comments: -?t'�{m1 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 CK RECEIVED BY DATE PERMIT NO. INFO CASH EH 13 24 IREV.t r x3Y , �jl c l>R L 5`( `C� l/✓oo EH 14-20 v