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i APPLICATION FOR PERMIT f —" SAN QAQUIN COUNTY PUBLIC HEALTH ERVICES ENVIRONMENTAL HTsALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ERM T EXPIRE { 1YEAR FROM DATE SII (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 1962 and the Rules and Regulations of San Joaquin County Public Health Services. 3 7 8 8 Ira� Z?A-,� G 1 z o S Job Address n City �' � Lot Size/Acreage Owner's Name 447oe— .Z ren Address �Q A-7ox S/3an�Ge�drl 3 7 Phone !: zy Z30d I Contractor e H Address .Z.�. O L✓. �i��AH /�� License No. X79.3 Phan .5-1a y83-742;o TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION J17rout of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP: LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C..; CI Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public Cl Other f 1 Deita Depth of Grout Seal Type of Grout CICI I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. State Work Done_ Wall Destruction ❑ WON Diameter Sealing Material 4 Depth Depth Tiller Material i Depth n TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION (No septic system permitted if public sewer is Is available within 200 feet.) Installation will!serve: Residence___. Commercial_._,. Other AI.ZA Number of living units: -:IIIA Number of bedrooms Character of soli to a depth of 3 teat: 2,"al IooZrrt Water table depth SEPTIC TANK ❑ Type/Mfg Capacityyr�X� r/ No. Compartments' PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line `` P LEACHING LINE Cl No. b Length of linea h Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 //n i! Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' I I hereby cenity 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 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 compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I unify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion larva of California." Thea titan nwst OQ for all req ' in s. Complete drawing on reverse side. $ nod .. Date �19 3 FOR DEPARTMENT USE ONLY Application Accepted byDate t Area v�T ✓ {j Ph or Grout Inspection by Date Final Inspection by Date Addhional Comments: l 050 s e Applicant - Return all copies to: San Joaquin sty Public Health Ser ea Environmental Health Permit/Services 445 N San Joaquin, P O Box 3009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTER CASH RE',C/EIVED BY DATE PERMIYNO, . IN 13-211IN&,11it. 56 IN �� [ ! D� I i �� I'�� t/tt�-,T 93�ot5 147a .—r