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er APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES- ENVIRONMENTAL -HEALTH DIVISION f P O BOX 2009; STOCKTON, CA 95201 (209) 468-3447 PEM13: EXPIRES 1 YEAR VR0g DATE ISSUED l { (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 1662.and the Rules and Regulations of San Joaquin County Public Health Services. / Job Address /r �1.� �RR,0Cq �� City Lot Size/Acreage Owner's Nam ti CLZDaZ2dajAr4aless - Phone •_Contracl r E +OSS L(Pr) A Address% 3 /E�\. Lin C A_5)__WQr a NoA306 Phone Sys~,�b 14 TYPE OF WELL"/PUMP: NEW WELL WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION Ea-' YSTEM REPAIR ❑ OTHER ❑ Monitoring Well n .► DISTANCE TO NEAREST; SEPTIC TANK J SEWER LIN/S DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 3n` OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Iu 121 C1Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing omentic/Private, Cl Gravel Pack ❑ Tracy Type of-Casing- 5pecihcation$ s C T `Pui#rlic �` is Other—*,-. ❑ Delta Depth of Grout Seal :, Type of Grout G Irrigation Approx. h . astern p �9ur<'ce Seal Installed by Repair Work Done U Type of Pump _ H.P. /S— State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth �• Depth Filler Material i Depth s TYPE OF SEPTIC WORK; NEW INSTALLATION I] REPAIR/ADDITION 0 DESTRUCTION GI (No septic system permitted if public sewer is k __ available within 200 feet.) ""I� Installation Will serve: Residence...,. Commercial— Other w Number of living units: Number of bedrooms " 41 Character of soil to a depth of 3 feet: . Water table depth SEPTIC TANK ❑ Type/Mfg ` Capacity No. Campartrttenta PKG. TREATMENT PLT, a- Method of Disposal.� �. Distance to nearest: Well Foundation Property Line r LEACHING LINE �C1 No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well ~Foundation Property Line LL - SEEPAGE PITS _ I I Depth Sire Number SUMPS LI_-Distance�tc nearest: Well Foundation Property Line t "DISPOSAL PONDS "0 ¢ I hereby cartify:lhat 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 foliowing: "I Certify that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as 16 Become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the periormance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- tion laws of California. , t o- The apple nt MpA call for r quired inspections. Complete drawin ferse side. Signed4, Title: / a /' - Date: - w FOR DEPARTMENT USE ONLY ` A ' XApplication Accepted by Date d n Area f-/ Pit or Gout Inspection by Dal Ob-7-,11471 Final Inspection by Additional Comments; Z4, W Applicant - Return all copies to: 'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y + ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 y� IFEE `AMOUNT DUE AMOUNT REELe 7MiiTTEO CASH ftECEIVED By DATE PERM17'140. �. EH'1321iREV.i/w51 Ti1pC � .W �'1t.,�� "a/ \ ��/aS`r EN: