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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCSTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM 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 comliance with San Joaquin County Ordinance No. .549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I Job Address Kr-'o GU ie�'lV5CY �'v e, City -Srt7C� oGy Lot Size/Acreage ' �6- Owner's Name AIA&C PF=T T/ Address YS 40 Gr�rrYse�s '_ Phone _--.... ter- fl/Y 7r ON' ^AtfdresS arIJU Z a L�>� v t.7 �. B �Z3`-V-9 Contractor L ii ansa No.-y4/P�� P� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ElMonitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial 11 Open Bottom CI Manteca Dia. of Well Excavation Dia. of Well Casing fl Domestic/Private CI Gravel Pack 0 Tracy Type of Casing Specifications f i'1 Public Cl Other Cl Delta Depih of Grout Seal Type of Grout I 1 Irrigation w Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump m - - H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth I: Diller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence L Commercial T Other Number of living units: Number Ad oft bedrooms Character of will to a depth of 3 feet: _.fa``�6� _ Water table depth � r SEPTIC TANK. ® Type/Mfg .A QlS/, e T Capacity—/ BOO No. Compartments � PKG. TREATMENT PLT.❑ Method of DisposalJN Distsncs-to nearest:--Well Foundation 4 Property Line Ia' [` LEACHING LINE 0,. No. & Lertgth of lines Total length/size $O [ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ILA Depth Xf Sire 3 �iA� Number �- I SUMPS Ll Distance to nearest: Well Foundation 6.� Property line 8 ' DISPOSAL PONDS ❑ f 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 t 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, 1 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 compansa- tion laws of California." . l The applicant st call for all required inspections. Complete drawing on reverse side. Signed Titis: Data: �-/1 " 9 Z ! , FOR DEPARTMENT USE ONLY ! t - 9- 13) p € Application Accepted by Date b" 1 3 - 1 Area Pit or Grout Inspection by I ` Date Final Inspection by Date LZ I Additional Comments: P.P, 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 INFO AMOUNT DUEi AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. i . EH I3-24 I�EV.r i LI 1! L II •- EH t4-7a