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APPLICATION FOR PERMIT . a d SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '"e'"/ ENVIRONMENTAL HEALTH DIVISION r u-e ft 445 N SAN JOAQUIN, PHONE (209)468-3420 d-es d. P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSRED' (Complete in Triplicate) Application in hereby rade to San Joaquin County for a permit to construct and/or install the, vork herein described. This application is made in compliance frith San Joaquin County Ordinance No. 51+9 and 1862 and the fiiules and Regulations of San Joaquin County Public Health Services. ' ] s Job Address(5:7 •i City 11I Lot.Size/Acreage t3 41 e_ Owner's NameAddress C? to 'Tli P_ ,e i &d _ _ Phone �" 3 C�03 I I Contractor h' Address ['��•. (�� yQ & /'7— License NoZ26C7 IS-3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL'REPLACEK4EN7 ---'—DESTRUCTION-O'Out,of-8ervice-wou'- ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLDD�. �� PROP. LINE FOUNDATION k AGRICULTURE WELL OTHER WELL._ PITS/SUMPS _— i INTENDED USE TYPE OF W6:12'^ "PROBLEM AREA CONSTRUCTION SPECIFICATI NS 1 0 Industrial Open Bottom ❑ Manteca k ` Dia. of Well Excavation Dia. of Well Casing a� Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S`YeG� T Specifications - I'1 Public l-1 Other 171-Delta, Depth of Grout Seal Typo f Groµt Ue m e rt� Irrigalion (��Approx. Depth •1 1 Eastern Surface Seal Installed by - 1 q h 3 t-,-1 -�-r w Repair Wark Done U Type of Pump 'f P u �f51� � H.P. �a � State Work pone Well Destruction O Well Diameter f Sealing Material i Depth 1 Depth a Filler Material i Depth O 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is s available within 200 leet,l Installation will serve: Residence Commercial_ Other l Number of living units: Number of bidrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg ' Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal II Distance to'nearest: Well Foundation Pr � operty Line i LEACHING LINE Cl No. b Length of lines Total length/size ± FILTER BED L7 Distance to nearest: Well Foundation Property Line � I SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 certity.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 taws 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 compenss- tion laws of California." i The applicant must call for all required inspection Complete drawing on reverse side. Sig net# A' Title: 5Q, '-Cdk-r[S. -- _. ...— Date: _ 7 A F D ARTMENT USE ONLY Application Accepted by Date Area PitGrout nspactlon by e Final Inspection by ate `13 Addltional Comments: A 4AP scant -r Re ur� all pies to: an Joaquin Co my Public Health Services V r_ �'� .- D Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 Ago FEEI INFO AMOUNT DUE # AMOUNT REMITED TASH ECEIVED BV /bATE PERMI7'NO. v . EHyEV l ��IR .r In at EH e4•25 / i