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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �� e //c)j /. FAST dk4,!XZ -0 24 v�, Cit J T0(2k_r V Lot Size/Acreage /, /-7 9Z r T V Job Address y-- f Zo 64s a44< ?i4cA_ _ 1 Owner's Name �'= '� e4�, IV-4 Address 6L sr�-�cf�? fCt* �tL`�� Phone T% �y Spm/o G�iu u �Ciq� Gtr, 5✓.:E /C, Controctdr,C6 .?r, =N�y�� AddressL"r�vCc �CJt `> ,!S2� License No. �(�i�f��J Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION CI Out of Service well ❑ '- PUMP INSTALLATION C] §Y,ST1=M F EPAIR L OTHER b / N n�torin�� l m�. . moi. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z r DISPOSAL FLD. PROP. LINE ��C• FOUNDATION A 6 R I C M Tb RE'\N kL L, _ -',OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA. CONSsTRUCT10V SPECIFICATIONS _ie SF 200o n Industrial O Open Bottom ❑ Manteca .Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy -"Tyrm of Casing-_ - •�. Specifications I'1 Public IX Other n Delta Depth of Grout Seal a Type of Grout I I Irrigation 5 Approx. Depth I I Eastern. Surface Seal Installed bX Repair Work Done U Type of Pump H.P. $tate Work Done Well Destruction O Well Diameter Sealing Material 3`Depth 1 CAII/ 455 r�tiµ��%1 Depth Filler,Material • Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ' I REPAIR!ADDITION i I DESTRUCTIOR I I INo septic system permitted if public sewer is • available rtnin•200 feet.I Installation will serve: Residence_ Commercial%__ ' Other Number of living units: Nurrlber of bedrooms Character of soil to a depth of 3 flet-.�:'�' �* Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. CI ; Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Founaaoon y Property Line SEEPAGE PITS 11 Depth Size = Number �t SUMPS 1_1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 of the work for which this permit is issued, I shall .not employ any person in such manner as to become subject to workmen's compenlatin jaws-,of California,'-Contrarctor'g hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which'this permit is issued, I shah employ persons subject to workman's compensa- tion laws of California." The applicant c 1 for all requi ed inspections. Complete drawing on reverse side. s Signed X Title: Lci:� .asr'1<�iy�1L '0l`ST Date: ��U _ FOR DEPARTMENT USE ONLY '`� ` ;/,�,•• "•• �_..* Application Accepted by _ Date Area ' Pit or Grouts 1dwection by Date Final Inspection by r ~'' Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, O Box 2009, Stkn, CA 95201 INFO EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT No. y// y/� EH 14-24 IREV.I Pae 13A insr / ' O / J �y / / �6 7� EH 1�.2e / / L