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APPLICATION FOR PERMIT SAN JMQUIN COUNTY PUBLIC HEALTH SERVICES �V-A ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �� r P O BOX 2009, STOCKTON, CA 95201 7 PERMIT E%PIRES 1 YEAR FROM DATE ISSUID (Complete in Triplicate) Application is hereby mede,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. Job Address 13,.3-2 1 ,57 Wee i City Lot Size/Acreage Owner's Name P_4P_tr[!lP /r644 Address 4 14 C H/ AALD feu ;7320 f Phone ' — —� r d Contracts f DrJ N Address i rii AlLe'S Y_0(pAp License No.a2 C2? Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTIONC$'Out of Service Well ❑ PUMP INSTALLA,�T�IOEN�❑ 11 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ous— SEWER LINES .S� DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _,l'v Dia. of Well Casing �Kbornestic/Private Gravel Pack ❑ Tracy Type of Casing_ pkt . Specifications i I'I PublicI 1 Other fl Delta Depth of Grout Seal Type of Grou I I Irrig � ation �/ypclnepprox. Depth I I Eastern Surface Seal Instilled hy////�� _/I 1�u YlJ/.r c Repair Work Don;70 Typo of Pump H.P. State Work Done _ Well Destruction t2�_ Well DismetpE� Materialr� Depth `( !9 Filler Material i Depth \-ef�eesrgt' —9S//�✓� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public ewer is \ available within 200 feet.) Installation will sere: Residence_ Commercial_ Other (l� Number of living unite _ Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation Property Line _ v LEACHING LINE ❑ No. g Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line (�\, SEEPAGE PITS I I Depth Size Number 11 n SUMPS LI Distance to merest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, end rules and regulations of the San Joaquin County Home owner a licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson in such manner as to became subject to workman's compensation lees 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, I shall employ persons subject to workman's compena tion laws of California." The applicant ywst call for MI required inspections. Complete drawing on raven" side. Signed x l c Ale&a Title: Date: rt FOR DEPARTMENT USE ONLY Application Accepted by Datey /�t Area r Pit a Grout napactionyby yy Date Final Inspection by 5 - Mete Additional COMManW _7.Y'll�'ytt:'yS(J "01 Lola(; iAa d,,—, Kh 'I yE/lI Applicant - Return all copies to: San Joaquin County Public Health S rvices f �' Environmental Health Permit/Services1 445 N San Joaquin Box 2009, Stkn, CA 95201At �� FEE AMOVNT DUE AMOU 7 REMITTED CK EIVED BY ATE ERMIYN �4 O F . EN 1344 IaEV.rrelp �/ / /1 q , EN t .y / t