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1*01, APPLICATION FOR PERMIT , � 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 vork herein described. This application is mde in costpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _3S N-ar4 Ut.r-ktc I!aNt City Ld�t Lot Size/Acreage S<trt Owner's Name v�r r4Ma/ �KC. Address J Z� rr��/ Ayca�7 /3Z?6 Phone�2l-02-,¢t 3241 FI4zot.--4-t eAlil ., Contractor K t�P �'t� Addresx a•t"hP�Cc�o y'a t"& 9— 47Z License No._tMPhoned (G TYPE OF WELL/PUMP: +NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER % Monitoring Well Se%I Left"$ _ 3 4•6 5,09 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 ❑ Industrial O Open Bottom O Manteca Ois. of Well Excavation Dia. of Well Casing n Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public n Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Weil Destruction O Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public rawer 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 fest: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O PAY of Disposal Distance to nearest: Well Foundation�gCOV ES LEACHING LINE O No. 8 Length of lines T*J.I : (V� FILTER BED O Distance to nearest: Well. Foundation-- A� A "v4 ALTH SE SEEPAGE PITS 11 Depth Sia r�1utR[ �A�- SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 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 California." The applicaZs/t call for all required inspections.s. Complete drawing on reverse side. Signed X !.�•..,rlsi l{t Gv. Uwf. Title: e44/ f Date: 2�r4 A; 14j tA� � V��/aa ai /tet' FOR DEPARTMENT USE ONLY Application Accepted by Date C Area , �i Pit or Grout Inspection by L` Date Z Final Inspection by 7Y Kul Date �� Additional Comments: Applicant - Return all copies to: San oaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ill INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. � . EN,3-24 IREV.1/45) l t;Gt�t7 �lY �- -(g EH 14-M ` I/ `