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APPLICATION FOR PERI(? SAr, JOAQUIN COUNTY PUBLIC HE 11- ICES l ENVIRONMENTAL HEALTH D iv 445 N SAN JOAQUIN, PHONE (2 9 8-3420l4' 1 '1 P 0 BOX 2009, STOCKTON, ; a#= # lY 1 O PERMIT WIRES 1 yEAg FROM (Complete in Triplic t Io')U1V Application in hereby made to San Joaquin County for a permit to construct n d/tir'SLeYwI� _/ aPP1lcAtion 1e made in coaOiance vith San Joaquin County Ordinance No. 549 is Joaquin County Public Health Services. the Aules and Regulations of San Job Address //i'7,5-/')fJ S AQ ,J nEtT City ?�k Lot 51 ze/AJccreage//� , ZtES ' Owner's Name1TtZf�n�t (t(1>>.0 r tMM� Address Contractor L. --Si 'X fl/ ./,tel; Address Fn.137( ///,�/, lav^4 J.y� License No�S�-$�$a/9��P\hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Vela ❑ PUMP INSTALLATION C3 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK i 11211-2 �! -2 SEWER LINES /n��' DISPOSAL FLD. -sa/ PROP. LINE / FOUNDATION S /GD' AGRICULTURE WELL L✓,9 OTHER WELL-,)&�P' PITS/SUMPS .(c1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industnal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation11 p Dia. of Well Casing ❑ Domestic/Private n Gravel Pack 0,Tracy Type of Casing Seal 40 9✓C Specifications InC12L I'I Public ❑ Other F1 Delta Depth of Grout Seal I>7 Type of Grout.(E7rTa,IT InryJation _Approx. Depth I I Eastern Surface Seal Installed by -5-/ M )-'U"�'�- Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction O Wall Diameter Sealing Material i Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK; NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is Installation will fens: Residents_ Commercial _ Other available within 200 lest.) Number of living units: __ Number of bedrooms \ Cheracler of soil to a depth of 3 (set: SEPTIC TANK Water table depth O Type/Mfg Capacity No. Compartments �\ PKG. TREATMENT PLT. ❑ Method of Disposal CS I to nearest: Well Foundation Property Line QA LEACHING LINE ❑ No. 6 Length of linea Totes length/size FILTER BED O Distance 10 nearest: Total Property Line SEEPAGE PITS 1 ) Depth Size PT _ Number r-Ti SUMPS LI Distance to nearperry line nC —�sGeandnion Pro r, DISPOSAL PONOS O 11�4��I I hereby cenifY that 1 haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulatiora of the San Joaquin County ` Home any or licensed agent's signature conifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not • y Person in such manner as to become,subject to workmen's compensation laws of California.- Contractor's hiring of subcontracting spall certifies the,following: "I sonify that in the performance of the work for which this permit is issued, I shall employ parsons subje,ct to workman's signatuisss- tion laws of California.,, The applicant must aN (y- 1 r rad p•ations. Complete drawing on reverse side. Signed TitIs S63 �J c^A/�F f1f1_1@X,cly�v/S^ 9-fy 53 Date: USE ONLY �OR DEPARTMENT Application Accepted by z 6 1 Due Area Ph or Grout Inspection by Date Final Ins pection by Dan 7 Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services O / �D p Environmental Health Permit/Services dJr 445 N Sas Joaquin, P O Boz 7009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO ]�(y�7/,/ 9 CASH Q DATE�j PERM17 NO. (�/ EHt3 24 4]s(A".ries, J f' 15 3-