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e APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSM .I (Complete in Triplicate) !i 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. J Y� 1,� Job Addresa S' q City r sf—AJ� `�Lot Size/Acreage 7y - ch WIec-h a X Owner's Name C a s 7/ (=r Address 4 !.t a l!a 0. I> era h f l Phone )160ntractor (EUIf,�- Address License No.- • Phone TYPE OF WELL/PUMP:- - NEW WELL ❑ - WELL REPLACEMENT n DESTRUCTION-0 Out of 'Service:Welrrz. -_:" ;I1 PUMP INSTALLATION 0' SYSTEM REPAIR 0 OTHER 0 Monitoring Yell + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .a I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,-.INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation _Dia. of Well Casing [Cl Domestic/Private ❑YGravel Pack 0 Tracy Type of Casing_ Specifications ['I Public C7 Other Fl Delta Depth of Grout Seal Type of Grout Iii Irrigation .Approx, Depth I I Eastern Surface Seal Installed by (/\ Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth ' } t t ;M Depth Tiller Material i Depth A } '7 C TYPE'OF SEPTIC WORK: NEW INSTALLATION t REPAIR/ADDITION I i OESTRUCTiONA1 (No septic system permitted if public sewer is a r available within 200 fee1.1 (n Installation viii serve: Residence Commercial Other Number of living units:JUoP Number of bedrooms Character of Boll to a depth of 3 feet: t Water table depth SEPTIC TANK. , Type/Mfg - o 0J CI�Q',fC__ Cao cit d O r C 1 I pa yam` No. Compartments PKG. TREATMENT PLT.0 Method of Disposal' �! Distance to nearest: k ��Well .1fFoundation�ropertY Lina ti LEACHING LINE No. b Length of lines Total length/size FILTER BED D Distance to nearest: Weil,� Foundation Property Line P �N oundation fJ roerryr LLinaO"- SEEPAGE PITS Depth Size Number SUMPS LI' Distance to nearest: ell p !r c }} DISPOSAL PONDS p I hereby certify that I have prepared this application and that the work will be,done in accardance.with San Joaquin county ordin_'>lpces, grate laws, and rules and regulations of the Son Joaquin county Home owner or licensed agent's signature certifies the following: "l certify that in the pert ormance•of the%o&k for which this permit is issued, I shall not employ env 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:"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 Califomis." r The applicant must call for all rewired ins coons. Complete drawing on reverse s��id,,e��.- 4ig " Title: -_.��1 ''1.- Date: r F 1ARTMENT USE ONLY i Application Accepted by Date Area E'.>2- Pit or;Grout inspection by Date Final Inspection by4Lu 114Date / Aad'nfonal Comments: / fir. 4 ✓�j a. � �n • ec9 ' s Se e 9. t / ,y Applicant - Return all Copies to: San Joaquin County Public Health 9ervi�es �aOh-�L+�3 / �� ,+ Environmental Health Permit/Services ' t_.I/ r o lV IY6�t .1 r 445 N San Joaquin, P d Box 2009, 8tkn,;CA 952011r •f_ _ -�d1��/ 4L } J7��yT , '.I INFO AFEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY... DATE PERMIT�NO. i1 . EN 132 in v.Iin5l � ]] EH 14.1e N