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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the vork 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 �� City '��A) Lot Size/Acreage /SaX A + Owner's Name ?`_r ZA1Z S 4! b Address A 11145 Phone -G Contractor__. F'to trDAsr, Address_7_AA 107?�rGAc'4T A i/X License No. �1s sZAZe Phone _44-C-39-7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [.I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications ['I Public Ci Other ❑ pelta -- Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth I I Eastern' _ ,._...Surface Seal Installed by Repair Work pone U Type of Pump H.P. I Stat*Work Done�. Well Destruction ❑ Well Diameter Sealing Material Depth - Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 09 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.) Installation will some: Residence!� Commercial_ Other , o�4 Number of living units: ___Z Number of bedrooms 4 f Character of soil to a depth of 3 feet: SAUD 0,-i-A a -Water table depth N SEPTIC TANK. ❑ Type/Mfg Capacity /4ea No. Compartments �- PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well /60'0- Foundation � property Line�_ R r (" LEACHING LINE L"1-�No. fi Length of lines 3-l"01 _ Total length/size FILTER BED ❑ Distance to�}nowast. Well ocra�' Foundation �� ` Property Line .rf SEEPAGE PITS l Depth d ' Site��!LX g p Number - SUMPS LI Distance to nearest: Well i 0e) Foundation 'Z 47 ` Property Line DISPOSAL PONDS ❑ I hereby comity 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not am&y 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 comity 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." -. The applicant must call for all required inspections. Complete drawing on reverse side. Signed Dace: _1 Z-,X2_f!q_7- SE ONLY Applic tion ,Acccepted by zs/_ ".V�"lkt Date -1` - Z Area d2-!f ,Pit-t5r rout'Inepection by T Date 1��Final Inspection by Data ti Additional Comments: Applicant - Return all opies to San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EN 13.241REV,I/x5! /4 11144, 60 Cl • 00 4k EN,..2s