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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIR.ES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby ode to Sam Joaquin County for a Permit to construct and/or install the work herein described. This application is made in ec11CIPllmoe with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sm Joaquin County Public Health Servlcez. f { Job Address _,21'37/ Al. 7f~yeNizR.L1 A_- aty,2:*rre.J VAJ Lot Size Acreag Owner's Name V.9 SrAA/A A F Address _SAYM 9 Phone W4 -,2r Contractor FI-0 kD we'yi> - Addressti A_!A DcJ yA,rr2,tT License No._Aj Y X176 Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT O" DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDAT16N AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS 1 El Industrial O Open 80111 G Manteca Dia. of Well ExcavationDia. of Well Casing Domestic!Pn'vate - ❑ Gravel Pack O Tracy'" -Type of Casing Specifications V {'1 PublicLI Other fl Delta Depth of Grout Seat Type of Grout k,,l I I Irrigation _.Approx{Depth I I Eastern Surface Seal Installed by J Repair Work Done U T p p Type of Pum _ H.P. State Work Oona_ Well Destruction D' Well Diameter 'Sealing Material &'Depth Depth Piller Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it putilie sewer is • r/ available within 200 feet.) O Installation will serve: Residence ✓ Commercial— Other + Number of living units: __J_ Number of bedrooms Character of soil to a depth of 3 feet:1 SA AJ b Y Lm4 rr, Q,T Water table depth SEPTIC TANK. _ Type/Mfg, P 9'-L Capacity �Z®o No. Compartments PKG. TREATMENT PLT. O . Method of Disposal r - Distance to clearest: Well Foundation A& r Property Line lady { LEACkING LINE w No. 8 Length of lines Z' SO Total length/size ue r FILTER BED ' O Distance to nearest: Wali �� /�FOUridatlon-4462�— Property Line /Sion SEEPAGE PITS Sltf Depth Size Number SUMPS CI Distance to nearest: Wall Foundation Property Lira DISPOSAL PONDS O I I hereby certity 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 a licensed agent's signature certifies the fokowing: "I certity,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 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 compensa tan laws of California." The applicant must call for all required inspgctions. Complete drawing on reverse side. Signed X Title:_1'�..r . Date: ��4Z- '�"F ((�� j 1 FOR DEPARTMENT USE ONLY q ^� Application Accepted by \LM.wA i Date -Z { ` L- Area at e Pit or Grout Inspection by ) Data Final Impaction by Date 7` { 2.. Additional Comments: e Applicant - Return all copies to:r San Joaquin County Public Health Services, PSfvironmental Health Permlt/Services • 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE 'AMOUNT t-FAMOL ,11T EMITTED CCI AKKRECEIVEDeVPERMIT'NO. SEX 1Y7x IREV,1185JEK 14-M L. V � '''') tit 3 / 27- "L„