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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH `SERVICES �1 r ENVIRONMENTAL HEALTH DIVISION}. P O BOX 2009, STOCKTON, CA 95201 if (209) 468-3447 C/ PERMIT EXPIRBS u DATR ISSUID E (Complete in Triplicate) Application is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This application is made In coupllance vit3i San Joaquin County Ordinance No. 549'and 1862 and the Rules and Regulations of Cyan Joaquin County Public Health Services. ub OC Or/ Lot 91ze/Acreage oQ'Job Address -9 CitC er Co i;,/7--y n !V� S 'Owner's Name - Address .r�2 q �c c D' S7�C Phone 'r Contractor K�-j�te.S��e Com ddress 19.5'2-- �l icense No. 6 ZPhone SR -O TYPE OF WELL/PUMP: ! NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION O Out of Service Well O PUMP IN CATION ❑ SYSTEM REPAIR O OTHER O Monitoring well C1 DISTANCE TO NEAREST:,SEPTIC TANK SEWER LINES' DISPOSAL FLLD PROP. LINE FOUNDATION GRICULTUAE WELL 0TH PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUC PECIFICATIONS Ll Industrial 010pon Bottom O Manteca ! all Excavation Dia. of Well Casing U Domestic/Private Cl Gravel Pack ❑ Tracy Type o asing Specifications M Public ,Cl Other O Depth of Gro Seal Type of Grout cJ Irrigation Approx. Os ❑ Eastern Surface Seal Inste by Repair Work Done U Type of Pump H.P. to Work Done _ Well Destruction O Well Diameter Sealing Haterial i Depth Depth Tiller Haterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION17 REPAIR/ADDITION 0 DESTRUCTION Cl INo septic system permitted if public sewer is r available within 200 feet.) / itcP 5� /fie Y>7 Installation will serve: Residence_ Commercial — Other e,_ Number of living units: Number of bedrooms 7 _ Character of,soil to a depth of 3 feet: � Water table depth SEPTIC TANK O Typs/M1p`\.. !.}l1- Co,✓c,-eTe' t4Capacity 1900 6QL No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well 11'X7 t Foundation t Property Line $ LEACHING LINE I, L + O No.:b Length oflines. .� Tote) length/sire FILTER BED '(� O Dietaries to nearest'`- Well /00 4- Foundation 5+ Property Line �S SEEPAGE PITS II-I Dept hC r Sire,�_ �� r cr Number _3 SUMPS LI Distance to newerreest: Well C-) Foundation Z Property Line DISPOSAL PONDS ❑ 1 hereby cenify'that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that In the performance of the work for which this permit is issued, I shall nc employ any person in such manner as to become subject to workman's compensation isws of California." Contractor's hiring or subcontracting signatui cenifies 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 compens+ tion laws of Cslifornlo." The applicant must cell for all required inspections. Complete drawing on reverse side. M 4 f X Signed Title: �ii�>,Q� ��E�'s� Cr' '1 Data: is a2(a FOR DEPARTMENT USE ONLY Date �h—Qa _.-Ar 'c , r Application Accepted by _ Pit or Grout Inspection by Date Final Inspection by Rat• `� Additional Comments: Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES q_ � p�p / ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES At.-.1b 445 N SAN JOAQUIN, P. 0 BOX 2009, STOCKTONJ CA 95201;!E FEE AMOUNT DUE AMOUNT REMITTED, CA SN RECEIVED BY" DATE SER NO. IN EH t�.J.II,EV.r,M�l 11 -1 1 L1 -%Iqae tam o