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-� APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT =IRES 1 FROM DATE 193 (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 Lad the Rules and Regulations of San Joaquin County Public Health Services. City -2r �a r �. In y �c C t L r• n c U/s l Lot Size/Acreage r_C✓C Job Address J ' ! f �j Address Lt1 14,1 �-� - �a��..� �� l7Z' OPhonei`-If 0,2-4 1 i Owner's Name ft< 24 ContractlJr Address rr:A-L f( In F (61,1.,,.c �A ^ License Nn. ' 0 2 T LU PhonQL�I��C� - �^ or WELL REPLACEMENT C DESTRUCTION 9 Out of Service Well ❑ TYPE OF WELL/PUMP NEW WELL © o4 v . +ds• Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom 0 Manteca Dia. of Wail ExcavationDia. of Weit Casing (7 Domestic/Private ® Gravel Pack ❑ Tracy Type of Casing Specifications 1'3 Public Cl Other n Delta Depth of Grout Seal Type of Grout I I irrigation '�O Approx. Depth I I Eastern Surface Seal Installed by Repair Wort Done L7 Type of Pum H.P. State Work Done _ { WaH Destruction Well Diartteter Z Sealing Material i Dept Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sower is available within 200 feet.) Installation will serve: Residence _ Commercial — Other Number of Living units: Number of bodrooms Character of sed to a depth of 3 fan: Water table depth et SEPTIC TANGO. ❑ TypoiMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lino LEACHING LINE ❑ No. i Length of lines Total length/size FILTER aED ❑ Distance to nearest. Well Foundation Property Line. SEEPAGE PITS 11 Depth Size Number SUMPS . . Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that l he"prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and rpulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: -t 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." Contractors hiring or sub-contracting signature certifies the following: -11 certify that in the performance of the work for which this permit is issued,I shelf employ persons subject to workman's compensa- tion fav*of Callfortt4." The applicant must call for as required inspections. Complete drawing on reverse side. Signed`/ /..-:l L ezx&ellr o Title- l.. -o/�- , s Date: �!/fw �.e..•�+w^^•-�� jvf �. ~fFOR DEPARTMENT USE ONLY � 9 J2, 7 Application Accepted by Oats Area Pit or Grout Inspection by Q f Date Final Inspection by Dais Additional Comments: WC5 II Applicant - Return all copies to: San Jol[quin County Public Health Services ��s-7 . Environmental Health Permit/Services v ' 445 N.San Joaquin. P 0 Box 2009, StXn, CA 95201 FEE AMOUNT DUE AMOUNT REli IrrEO j RECEIVED 5yDATE PEflMIT,NO. INFO Oa�2 S>� E!1 147!