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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Z 7�7S /�� I_Yt�s City Asa t Lot Size/Acreage 16,a0 qca. Owner's Name At 01 +1S)tr;- Address 2'? SOL (e-5 f�1:) Phone 333 Conlractor 6rr_S Address ho R", 1743 License No. �'fQ S�4 Phone 337-Z. �zt TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well Cl PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well 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 n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack O Tracy Type of Casing Specifications M Public [_1 Other O Delta Depth of Grout Seal Type of Grout CJ Irrigation —_ Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION x REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if 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: SC.,�Lj -1,4 Water table depth SEPTIC TANK fd Type/Mfg t?'� L Lc„cj r h Capacity. cU II lr l^ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Z Distance to nearest: Well /7Qc Foundation ZS r Property Line 4 LEACHING LINE 0 No. 8 Length of lines _ 3 A 4 6o Total length/size r (- FILTER BED O Distance to nearest: Well »U Foundation Property Line 4S`moi r SEEPAGE PITS 11 Depth Z 3' Size 4 " / nq -- Number - -3 C SUMPS LI Distance to nearest. Well Foundation Property Line 4)--670 DISPOSAL PONDS O v 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 1` D 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- tiorrwws O The applicant must ca for all awired inspections. Complete drawing on reverse side. Signed X -- g �� '`-" � Tide: _C o,,Sir.,c 1*; Sr 1��,,. t-i•aa.�F.ti Date: FOR DEPARTMENT USE ONLY Application Accepted by — /I Date 1 Area C;2/Z nor Grout Inspection bye- x'11 U Date S 1- -`ly Final Inspection byrl/\(C2 --� Date Additional Comments: _`� o YP-kiZ U S G•f r 1 n ck r srae cX1'0, __ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 13 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CEIVED BY) DATE PERMIT NO. ,3.24 Into.I,xOi ie�PG