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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 EXPIRES _ __BEAR fR_0JLDAJ,U ISSUED (Complete in Triplicate) Application in 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. Job Address iD 5?9XS, /A2LAN �2 D City )C�',C. Lot Size/Acreage i4GR�5 Owner's Name u M S /Address PQ-0503 Contractor /40M E; L O&Z> Address 7 Al. DEd e� T � License No. �y��"�G Phone LJ-397/ ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .._ INTENDED USE TYPE OF WELL PROBLEM PEA CONSTRUCTION SPECIFICATIONS ri Industrial ❑ Open Bottom ❑ Manteca D' , of Well Excavation Dia. of Well Casing I U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications t C1 Public 1-1 Other 0 Delta Depth of Grout Seal Type of Grout CJ Irrigation Apprax, pepth ❑ Ea n SuAace Seal Installed by Repair Work Done. L] Type of Pump H.P, State Work Done f Well Destruction O Wolf Diameter Sealing feria) i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION . REPAIR/ADOiTION Ll DESTRUCTION G ]No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence. Commercial Z Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Al D G Water table depth SEPTIC TANK if Type/Mfg e-C_ —P9F L Capacity ad767 No. Companrnents Z PKG. TREATMENT PLT. 0 ti Method of Disposal Distance to nearest: ell Foundation--_/-s Property Line LEACHING LINE No�B Length of lines - /,D(,!J�, Total length/size OC r FILTER BED n ,Distance to nearest: Well Foundation 7,tV Propeny Lina //-)O'� SEEPAGE PITS f I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I).. - - 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 l 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 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 California." 'I The applicant must calf r altre wired inspections. C mplete drawing on reverse side. Signed 4� Title: Date: /,0�f 7—9 a FOR DEPARTMENT USE ONLY 4 Application Accepted try oat e)© -f�o Area �._7 p Pit or Grout Inspectlo Date Final Inspection by. 011 Date 1 I r 0 r Additional Comments- ter. 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 CASH RECEIVED BY DATE PERMIT N0. . EH -74EREV.tiKSi ��DI 4511D-1q-C/0 (H 1.4-30