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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 E%PIRES 1 SEAR 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 wade in Compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules Lad Regulations of San Joaquin County Public Health Services. Job Address 260 SO. IM,41A) 4 City,04A)Z�i4 Lot Size/Acreage •ZS'AG 5-STA-rr= OF- Owner's FOwner's Name A&AOL1t AS427A• Address S30 Y449 S1. SAA)E3AAx'tSea 44139 Phone 1 $ -66317 OSTIER 8 EtZe, 2-5-73 A2-000- �?o � (Zoq Contractor S A- 44' A;'r Address s"3 / License No.44/.L7Q Phone TYPE OF WELL/PUMA: NEW WELL O WELL REPLACEMENT CJ DESTRUCTION Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O �OTT�HER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ,�1_. SEWER LINES sjEM�' DISPOSAL FLDAW PROP. LINE 110 FOUNDATION .3a' AGRICULTURE WELL NI OTHER WELL 102-L— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial O Open Bottom Manteca Dia. of Well Excavation 4" Oia. of Well Casing {Q Domestic/Private W Gravel Pack C7 Tracy Type of Casing_$CHAQ P0e-- Specifications C] Public 1:1 Other O Delta Depth of Grout Seal 512,eAcle Type of Grout M Irrigation —.Approx. Depth ❑ Eastern Surface Soul Installed by_C'W r',Z+cstiz- Repair Work Done U Type of Pump H.P. State Work Done _ Will Destruction Well Diameter Sealing Material i Depth Depth Tiller Material 4 Depth TYPE OF SEPTIC WORK: NEW'INSTALLATION n REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: WI. le SEPTIC TANK. ❑ Type/Mfg Capacity N X FU r I I PKG. TREATMENT PLT.O M Distance to nearest: Well Foundation - Properly Line LEACHING LINE 0 No. b Length of lines Tot lEkffH FILTER BED 0 Distance to nearest: Well Foundation Property LKRmma1!SLR SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby comity 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 conif'Ies 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- tion laws of California." The applica71na U� all r u' ins ctions. Complete drawing on reverse side. /,� Signed Title: � �+�� Date: A`,4aW 2?IFU FORDEPARTMENT USE ONLY ri Application AfCcopted by ` Oate Vla Area v Pit or Grout Inspection y Date Final Inspection by d Date Additional Comments: — Applicant - Return all copies to; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 Ab CASH AECEIVEO BY DATE PERMIT'NO. t.z,ISN. r7 0- -,� q3 spa