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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC REAL RICES ENVIRONMENTAL HEALTH El . -1 445 N SAN JOAQUIN, PHONE (209 4f20 P 0 BOX 2009, STOCKTON, CA 95�((++1T{{r�� PERMIT EXPIRES 1 YEAR FROM DATE@�S@n - — - (Complete in Triplicate) ,�/ # Application is hereby made to San Joaquin County for a permit to construct end/or ins application Is aside in ceelPliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and RegulAtlons of San Joaquin County Public Health Services. Job ddrau a 6 a o� Q City-t'b� Lot Size/Acreage Owner's Name 'ULAddress S AI tie Phone Conbactor Address nG.kn �� j "\ License No. Pnone -a ' TYPE OF WELL/PUMP: ` NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out h Service gall PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Industrial II Bottom ❑ Manteca Die. of Well Excavation Du. of Well Casing O Domestic/Povare Ll Gravel Pack ❑ Tracy Type of Casing_ Specifications ('I Public Ll Other Ll Delta Depth of Grout Seal Type of Grout tie I I Irrigation _ Approx. Depth I I Eastern Surface Soul Installed by ' Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depthi� Depth Tiller Material 4 Depth R. TYPE OF SEPTIC WORK: NEW INSTALLATION.Pi; REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is W available within 200 feet.1 Installation will serve: Residence- Commercial _ Other .J Number of living unite —L Number of bedrooms _.--',7 .._ Character of " to a depth of 3 feet: Cl W-Y r ' SEPTIC TANK i1g'A Water table depth K Type/Mfg L1IN'1 -ryCapacity J f�fp No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well P0 Foundation ----b J Property Lina ISb r LEACHING LINE fril- No. 6 Length of lines C-n 14c) , Total length/size 44 !!l��,,, FILTER BED O Distance to nearest: WeN JZn Foundation �O y Property Line /SD J ^I _.� SEEPAGE PITS h4 Depth Size--3f 't Number 4 SUMPS LI Distance to neansr. Well / 647, Foundation SO r Property Line /SID DISPOSAL PONDS O II 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 agents signature certifies the following: -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." Contractor's hiring or subcontracting 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 composts- Tion laws of California.- The applicant most call Jprr requir ins ctions. Complete drawing on reverse side. Signed X 2�/(JI/ rr Title: CX-Z>11 t31L Date: Li CDEPARTMENT USE ONLDate Area FORY Application Accepted by r l �nl or Grout Impaction DV � iIL/Ca•^�" pat%7��i' Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Bos 2009, Stkn, CA 95201 / FEE AMOUNT DUE AMOVNT EMITTED RECEIVED BV DATE PERMI7N0. {' INFO CASH t ;:mlap, ,,.,, — ;iU J � i �sr "Clay