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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 f ' p O BOX 2009, STOCKTON, CA 95201 PERIfIT EXPIRES 1 YM FRQM DATE S :E $ (Complete in Triplicate) Application is hereby made to Sam Joaquin County for a permit to construct and/or install the vork herein described. This application in made in compliance vith Sam Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3 o�Frr��6e1 City ,lAD/ Lot Size/Acreage r,L%Ac �'v n /�9/4� - �,Addiess Cl�Afar4S�K� Phone Owner's Name Y-E A ��537� Phone 5$7/ Contractor L-4 � �• Address /fir ��t'�� t License No. , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well 0 T !-PUMP INSTAL'OOON O SYSTEM REPAIR C3OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK.' SEWER LINES DISPOSAL FLD. PROP. LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE --TYPE OF WELLS PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial r ❑ Open Bottom ❑ Manteca Die. 01 Well Excavation Die. of Well Casing [I Domestic/Private ❑ Gravel'Psck ❑ Tracy Type of Casing- Specifications II Public 1-1 Other N f n Delta Depth of Grout Seal Type of Grout � sus) —.Approx. Depth t I Eastern Surface Seal installed by j I 1 Irrigation i + Sate Work Done Repair Work Done 0 Type of Pump y•H.P. Wall Destruction ❑ Well Diameter Sealing Material ii Depth '^ _ - Depth 4 Piller Material i Depth ,TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIAIADDITION I I DESTRUCTION i I (No septic system permitted it public sower is A available within 200 feet.) Installation will serve: Residence—' Ctxtimercial Other X e-I A71 SNoP + Number of living units: Number of bedrooms W/1A7m O j Character of soil to a depth of 3 feet: . ��-A,� _Water table depth SEPTIC TANK. ❑ Type/Mfg ' 1- Capacity No. Compartments _ t Method of Disposal PKG, TREATMENT PLT.❑ + ,f Well Distance to nearest: WeHaiLO-'� Foundation�- Property Lined LEACHING LINE No. & Length of linea _ _ • T� Total length/size lee r f,f FILTER BED ❑ Distance to nearest: well undation, S Property Lina j SEEPAGE PITS IH" Depths -- Size !r Number SUMPS. Ll Distance to nearest: Well 3OC)#- Foundation Gd ` Property Line XC, i DISPOSAL PONDS ❑ l' 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 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 poii"nsation-laws•of California." Contractor's hiring or sub-contracting signature certifies the following:"1 cerliN the,in the performance of chs work for,whish this permit is issued, 1 shall employ persons subject to workman's compensa tion laws of California." The applicant must call for sit required inspections. Complete drawing on reverse side. j Signed )c_ �,n„�C._ — Title: Date: I FOR DEPARTMENT USE ONLY 1� Application Accepted by Data -�3 Area 2 - Pit or Grout inspection by Date }' Final inspection by Data Additional Comments: c + Applicant - Return all Copies to: San Joaquin-County. Public Health Services Environmental Health Permit/Services 445 N San Joaquin; 'P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMlTTEO CASH RECEIVED BY DATE PERMI'I*NO. L�V INFO . EH 1121[REV.$,,A 5) oe 11•36 - r�