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k APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i a ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 r P O BOX 2009, STOCKTON, CA 95201 M i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (Complete in 'Triplicate) Application is hereby medeto Ban Joaquin County for a permit to construct and/or install the vork herein described_ This application is made in ceuiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of pian Joaquin County Public Health/Services. Job Address r C City /.fOD-.1J Lot Size creage Owner's Name _ �� -Ser-1 Address X4"7 Phone 7 A4 4 p et-6Z-,e r Contractor ✓ Address--§-7 Crt/ ]IS" License No. y2!!s].7& Phone ' _3 7/ TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service iielx Cl PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ 14onitoring Well ❑ -� 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 �r C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private Cl Gravel Pack7 ❑ Tracy Type of Casing Specifications 17 Public n Other n Delta Depth of Grout Seat Type of Grout F_ I I Irrigation —.Approx. Depth I I Eastern _Surface Soul Installed by Repair Work Done U Type of Pump H.P. Stat4 Work Done _ Well Destruction ❑ Well Diameter Sealing Naterial i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public sower is available within 200 feet.I i Installation will serve; Residence! Commercial_ Other f Number of living units: _L Number of bedrooms _ 3 •— m4 j Character of Soil to a depth of 3 feet: Water table depth I v SEPTIC TANK. ❑ Type/Mfg I Capacity-12=9n— No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 01) Distance to nearest: Well Foundation %$(9 ` „ Property Lina LEACHING LINE No. 8 Length of lines 3-4to Total length/size €.' FILTER BED Gl Distance to nearest. Well J§L � Foundation � PeY Property Line .:5147 r +n V . i I SEEPAGE PITS I Depth Size sr Number 3 SUMPS LI Distance to nearest: WeFoundation ' Well Property Lina /s � DISPOSAL PONDS 0 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 cenifies the following: "I certify that in the performancs.of the work for which this permit is issued, 1 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, 1 shall employ persons subject to workman's corttpenss- 1 tion laws of California." F. The applicant must call for ail required ins coons. Complete drawing on reverse side. I Signed L . Title: 1110 Date: r lFOR DEPARTMENT USE ONLY -- Application Accepted by Date Area ,t� � r f or Grout Inspection by Date �_ Final Inspection by_Z _ �� - yDat4 J . Additional Comments. t -Applicant -- Return all copies to: San Joaquin County Public Health Services Environmental'Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED By DATE PERMIT'NO. ry 1 Ht�mIAEV.tin5) " �. ' ( [ , 90 / !! /