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APPLICATION FOR PERMIT _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR PROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /� Z7�7� � ��4�/PS City r[ a ag ��J•(JO XJca. Job Address Lot Slze/Acre e Owner.a Name At(-hf CS ,i Address Z7 rrr 7S So LJ (P.5 2Z) Phone 337-72� Contractor Address :P 0-(26 c 1 7Q? License No. <,-Y�5��f Phone _3232,b-0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C.] 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 fl Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public (_1 Other O Delta Depth of Grout Seal Type of Grout ` CJ IrnUauon _ Approx. Depth ❑ Eastern Surface Seal Installed by —S Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 DESTRUCTION F-I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _k Commercial_ Other Number of living units: Number of bedrooms _ 4 Character of soil to a depth of 3 feet: r ?y( L1 Qy Water table depth n SEPTIC TANK 9 Type/Mfg ? , L Cs„c, z�c Capacity 1r(ncc) No. Compartments PKG, TREATMENT PLT, O Method of Disposal z Distance to nearest: Well /7o Foundation ZS r Property Line 4S LEACHING LINE ❑ No. 6 Length of lines 3 A 4 6o C`A Total length/size C FILTER BED Cl Distance to nearest: Well 7C1 Foundation %S Property Line SEEPAGE PITS 11 Depth _Z S"_ Size 4 er Number :_.�T _3 inn/ SUMPS LI Distance to nearest: Well _LJ_ Foundation Zi— 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 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• tia2�i"wa o The applicoant�musst ca for all a u+red inspections. Complete drawing on reverse side. 1 Signed Title: Cr �S�r�C�o Sc,�G'," t.t�e�l�t? Data: i1-f5-Ci0 FOR DEPARTMENT USE ONLY Application Accepted by '�� Date /� /� Area /Z n � i'Z1 Pit;or Grout Inspection by,�- h u --- Date I-'IrJ Final Inspection Date �y l � L Additional Comments: CI c�- t'_ c,6i o_ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRUNMENTAL HEALTH DIVISION PER41T/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 INFO AMOUNT DUE AMOUN/T,REMITTED CASH CEIVEO B� DATE PERMIT NO. EH 13.74(REV.rinoi /Ay, EH 14.76 f3 I / /7 ✓