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w APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES I -YEAR PROM DATE 18,01 (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 Serviceea. Jot) Address Zun ems'/ �a�__ __ City M Lot Size/Acreage Owner's Name � ►�oi✓A, Address O(AM 4, Phone Contractor "#A ,relAt a Address r12427S C431212t"dt►-�Woc.17 License No. Phone 2=hi�Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Gl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [3 - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing [J DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1-1 Other 4. , 0 Delta Depth of Grout Seal Type of Grout CJ IfriUalion ,T.,'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 ` f Depth Filler Material i Depth TYPE Of SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION DESTRUCTION G INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living unite Number of bedrooms _3_ _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK aO Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C1 Method of Disposal IF Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER I3ED n Distance to nearest: Well Foundation ZJ2 Property L+•ne/D!________ t i SEEPAGE PITS ,IW Depth -1 " Size ZiIv Number- SUMPS l_I Distance to nearest: Well � Foundation i42,4 Property Line 19_=____� DISPOSAL PONDS D 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 at 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 thi performance of the work for which this permit is issued, I shall emptoy persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections, Complete drawing on reverse side. Signed Title: t.�tsr - - _._. Date: M-1Z•91D -130 OR DEPARTMENT USE ONLY `. A plication Accepted by Date l0 77- d Area Date Z` + Pil Grout Inspection by Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 945 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 tFEE AMOUNT!DUE AMOUNT REMITTED CK ASH RECEIVED ey DATE t'ERMIT NO. . EH 13.24 OtEV.i K 51 1 r