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APPLICATION FOR PERMIT i SAN MAQUIN COUNTY PUBLIC HEALT�+p0VICES Gni J Eh V I RONMENTAL HEALTH DI I ii�V9f 445 N SAN JOAQUIN, PHONE (2 420 P O BOX 2009, STOCKTON, A PERMIT EXPIRES 1 YEAR FROM AFAG (Complete in Tripliclt* # _E�) �l Application is hereby made to San Joaquin County for a permit to construct an insta I+—r$ application is made in compliance with San Joaquin County Ordinance No. 549 and 18 2 and t e es an Joaquin County Public Health Services. y Job Address ( � �� t c1�1111 �l kis — City M�-�\--e,c ,_L.ot Size/Acreage—_�j Z`X r?, X Owner's Name S'rlei u Its 4i iL.e_ C•T. Address P Ae4- 72 S_ 14c"ctc_-, � Phone Contractor i r Address E. { License No. Phone �t6-5-?712- TYPE OF WELL/PUMP: NEW WELL 01 In( criI)WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑t`atiPMonitoring Well-s 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 ❑ Industrial O Open Bottom `Manteca Dia. of Well Excavation )` Dia. of Well Casing r� Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing?VC P43S_' SC�,0.4 Specifications 0,01 Q Il Public (-1 Ocher F1 Delta Depth of Grout Seal 1 r Type of Grout n f3 ` I I Irrigation 'Approx. Depth I I Eastern Surface Seal Installed by �Tt1ti1 L 11 Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material E Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: C Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well ndation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: ell Foundation Property Line DISPOSAL PONDS O 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 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 subpct 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, I shall employ persons subject to wo(kman's compensa- tion laws of California." The applicant must call required inspections. Complete drawing on reverse side. Signed x ��+/ Title: �'�'�^C�� `'�� Date: 3 FORD PARTMENT USE ONLY Application Accepted by Date j Zd RAY PNT 'El V Pit or Grout Inspection by I,,,/•�� Date Final Inspection by c s Q 3 Additional Comments: �>/S 1 KI�G��&1A) S, 111 ly Z) 1��?l/�l3 SS `�� Applicant - Return all copies to: San Joaquin County Public Health Services SAN JO (� RVICES Environmental Health Permit/Services PUBLIC HEALTH `' V SION J 445 N San Joaquin, P O Box 2009, Stkn, CA 9F-WRONMENTAL HEALTH D FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFQ SN 1 EH 13.24 utEV.r 14sl Vi