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APPLICATION SAN YAQUIN COUNTY PUBLIC HEALTH S9VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 i P O BOX 2009, STOCKTON, CA 95201 i� 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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Z,]� �o�r i1Sl�aj :5;QG ` CitySf'��W Lot Size/Acreage �•S Job Address I, Owner's Name "41101V _TC 6C00q&4*W)1 Address Ivy .��6�!r"_"). Phone 1+r I X233 Ft Gti ►� ST- Contractor OAAMAT Adaress tv 9B`ice License No. C'� PhonL�7�b ��-1 7 �+`r TYPE OF WELL/P,UMP: NEW WELL' WELL REPLACEMENT ❑ DESTRUCTION o Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �T SEWER LINES DISPOSAL FLD. PROP. LINE I. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ti� ❑ Open Bottom 0 Manteca Dia: of Welt Excavation 06144 Dia. of Well Casing -IN�rf �Q Domestic) rive ❑ Gravel Pack rY' Tracy Type of � -Casing �^ '-A• 140-- Specifications Il Public F4 Other$Ad�rD OW4 X Delt�7Tpf�(W Depth of Grout Seal _�/� eT /Type of Grout AICWr C ' e7l T I I Irrigation Approx. Depth l i Eastern Surface Seat Installed by.Ct iT +tt C Isf t• ` T Repair Work Done (J Type of Pump H.P: State Work Done Well Destruction, ❑ Well Diameter Sealing Material L Depth Depth Filler Material & Depth TYPE OF SEPTICIWORK: NEW INSTALLATION I I REPAIR IADDITION f l DESTRUCTION I I INo 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 adi'i to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg ` capacity-- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINEI' ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line i SEEPAGE PITS '! 11 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will bs done in accordance with San Joaquin county ordinan6es, 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 componsation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which chis permit is issued, I shall employ persons subject to workman's compensa- tion taws of California." - E The applicant 1t call for ail required inspections. Complete drawing on,reverse sidec� � FD / Signed � Title: Date r i. ¢� OR DEPARTMENT USE ONLY Applicati n cce0ed by Date . ,74 Area ��' Pit or Grout Inspection by } Date Final Inspection by Date Additional Comments: mat 1 bv�t I Applicant , Return all copies to: Sae Joaquin County Public Health Services Environmental Health Permit/Services -445 N San Joaquin-, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO CTRL If i1 r jr�� f1/L 7 /JJ��JJ�! . EH 13.24 IAEV.l rnsl .� lJ 1+.'�,J ,J i.r Y+�� `-103 1 EH 14.20