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APPLICATION FOR PERMIT SAN 1AQUIN COUNTY PUBLIC HEALTHI'-VICES ENVIRONMENTAL HTALTH DIVISI 445 N SAN JOAQUIN, PHONES (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I Y YAR FROM DATE 192SE12 (Comp'lete' in Triplicate) Applicationiids hereby srrde•to Ban Joaquin County for a permit to construct and/or install the work herein described. This applieation,is grade in compliance with San Joaquin County Ordinance No. 5L9 and 1862 and the Rules and Regulations of Ban Joaquin County Public Sealth Services. ` Job Address Z 6�l85 Thorrr ON City Th d eM ADH Lot Size/Acrcege 0wMra Name' Barbara Dvake Add,.. 8315 "/4rroyo Phone 10 -?St -?979 Add,.. Sf Contractor l oru % Address r• �• &X License No. S�2L9�/ Phone7A1'7WsZt" er S 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 1) SYSTEM REPAIR ❑ OTHER Jk 1lonitoritlg Well ❑ I ly A Hd DISPOSAL FLD. 'NI b, PROP. LINE NA-- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION a4. AGRICULTURE WELL �— OTHER WELL -- PITS/SUMPS f�@l INTENDED';USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation—2o r, - Dia. of Well Casing •S"^• Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Pvcn Specifications I'l Public Other I"1 Delta Depth of Grout Seat _lSt+. _ Type of Grout b few. nca4 Case.++ = wry I I Irrigation 1SAF Approx. Depth I 1 Eastern Surface Seal installed by SES J Repair Work Done U Type of Pump H.P. State Work Dane _ Wen Destruction O Well Diameter Sealing Material i Depth 1 Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available Within 200 feet.) Installation will serve: Residence_ Commerciat_ Other . Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line does +.o�Oft 14 SEEPAGE PITS I ) Depth Sue Number SUMPS i LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t C1 t,-% a,...t Ckipplill 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 regu4pons of the Son Joaquin County Horne owner or(licensegencertifies d at's signature the following:."I certify that in the performance of the work for which this permit s issued. I shalt not person employ any pson in&Loch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractino signature certifies the 10"Vq:"I CoRify 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 Celifomle." TheT,4or =ir0ons Complete drawing on averse side. wffer f X4l�11141.t _ Date: 14714M7 Sig Title row FOR DEPARTMENT USE ONLY ApDate Area Ph or Grout Inspection by Date Final Inspection by Date Additional Corr►menti: �r Applicant' - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Pox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED x RECEIVED By DATE PERMIT N0. INFO CASH • EM 13•T�ittN.riR7m EM r♦-76