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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH `SERVICES r ENVIRONMENTAL HEALTH DIVISION.r P O BOX 2009, STOCKTON, CA 95201 �f t (209) 468-3447 (/ PERMIT ZUIRAS 1 YEAR SROM DATE ISSUED k (Complete in Triplicatt3) Application is hereby merle 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. •' Q S p 5T-,-e I City OCK7T^ Lot Site/Acreage t Job Address •'2/ _ t t0W/./ ��r.c�/�r� Gt�PS/ Nc�/97(= �. ''Dwnar's Name Address �¢.o D' ^�Phone ddress 1 ` �l �P icense No. �� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well ❑ PUMP IN CATION ❑ SYSTEM REPAIR C OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST:,SEPTIC TANK SEWER LINES' DISPOSAL FLD PROP. LINE FOUNDATION GRICULTUFIE WELL OTH L PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM A CONSTRUC PECIFICATIONS Cl Industrial 0]Open Bottom ❑ Manteca ! ; all Excavation Dia. of Well Casing G Domestic/Private Cl Gravel Pack C7 Tracy Type o acing Specifications D Public I 1 Other O Depth of Gro Seal Type of Grout ❑ trr gation _Approx. De O Eastern Surfice Saul Insta by Repair Work Done U Type of Pump H.P. to Work Done _ Woo Destruction O Well Diameter Sealing Material i Depth Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIWADOITION 0 DESTRUCTION U (No septic system permitted if public sewer is r available within 200 feet.) / Instillation will serve: Residence_ Commercial_____ Other rvcc e-`zT IyA•me.�. Number of living units: Number of bedrooms 7 �J 1/1 Character of toil to a depth of 3 feet: �r Water table depth SEPTIC TANK ❑ T'1141q' I�Ifl- CV,✓c,-crP t'`C+Fecity�/2100 64-` No. Compartments PKG. TREATMENT PLT, ❑ Method of,Disposal Distance to nearest: Well 11'X0:t Foundation 1 Property Line I } 1 I.� r �� LEACHING LINE ry_ ❑ No.:'8 Length oflines. �' Total length/site FILTER BED ` M Cl Oh iarice to'nearest,- - Well /00+ Foundation�5+ Property Lino ,S _ SEEPAGE PITS �0Ifl Depth Number SUMPS LI Distance to nearest: Well /.Sc AFoundation Zr� Property Line DISPOSAL PONOS ❑ I hereby cenify'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 rodulations of the San Joaquin County Home owner or licensed agent's signature certdies the loilowrng: "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."Contractors hiring or subcontracting signature sonifies 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 contpensa• tion laws of California." rho applicant must call for all required inspections, Complete drawing on reverse side./ X Si nod X Pf c L Prl�r sJ Title: 0i&&Ze--1 / �.. T. `_.� .� Date: SL FO�R�DCEPARTMENT USE ONLY ��1 1\ � t[J — Qt'' t Application Accepted by - Dote �o` _ -Ar Z ^ Pit or Grout Inspection by Date Final Inspection to Dats Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �C51 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERV CES �-.}b 445 N SAN JOAQUIN, P. 0 BOX 2008, STOCKTON CA 85201Z A S o rn. I FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE `BERr� NO. tH t1.1�rRcv.iia er fN 1�•>i