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. I! APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION t&O i 445pONSAN JOAQUIN, PHONE (209)468-3420, 4 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 cealpliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of Sun Joaquin County Public Health Services. F Job Address 3 9 City 7 Lot $ize/Acreage i Owner's Name jp� J V hCL/°Z Address �1 _Zretz Phone Z �Q Contractor Address t,52Z 1 .License No. ,,��i�X/3 Phone TYPE OF WELL/PUMP: U WELL El WELL REPLACE ENT DESTRUCTION XOut of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK -_� SEWER L1NE5DISPOSAL FLD. PROP. LINE _Z0_ FOUNDATION AGRICULTURE WELL OTHER WELL 4 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing XDomestie/Privole XGrovel Pack 1)9 Tracy Type of Casing_ �OkT11 Specifications 1h D f'1 Public [I Other, n Delta Depth of Grout Seal __ Ir77 Type of Grout t[� I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P, Stat Wark Dona Wall Destructionr� Well Diameter Sealing Material i Depth 1C Depth; Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION I I INo se ie systemvpermitied it public sewer is v available within 200 feet.) Installation will serve: Residence___,_ Commercial Other Number of living units: i! Number of bedrooms Character of$OR to a depth of.3 feet: Water tabledepth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 !i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. S Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth Size T Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, an rubs and regulations of the San Joaquin County Homs 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 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 compensa- tion laws of Cali nla." li The applicant 81 toll for,all requir speetions. Co plate drawing everw side Signed i ja Titl ti �/ Date: FOR DEP MENT USE ONLY -C Application Accepted by . Date 1 Lmµ Area �rs� Pit or Grout Inspection by 41 Date Final Inspection by Date ^" 10-13 Additional Comments: ((JJ 01 1 Applicant - Returis alli.copies to: San Joaquin County Public Health Services ^� Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2005, Stkn, CA 95201 I FEE AMOUNT DUE AMOUN INFO T REMITTED K CASH RECEIVED BY DATE PERMIT'NO, 1 . . EH 1344 411EV.t i 04'6Ya - CI r r C]�••-. EH 14-m � l r f� 3 r Z••rf"� I / �� t 7 1 nD