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R : APPLICATION FOR PERK[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 j (209) 468-3447 r2EUJT EXPIRES l YAR rROM DAIS ISSUED I (Complete in Triplicate) " Application 1e hereby made.to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance +r1th San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. t Job Address 4 L City Lot Size/Acreage P s t� 460 E 23 753E Owner's Name ��G �� Address � �� +41- P�e�� Phone CA LAR W. /�[CSS;Wt) Address 52.8 L£ t RMS �r�E_ V_.54a l Phone t-bz 7! _r - License No. TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT I1 DESTRUCTION ❑ Out of Service Well ❑ # PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER Q Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK T SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r. n Industr ill ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private Cl Gravel Pack ❑.Tracy Type of Casing Specifications M Public El Other © Delta Depth of Grout Seal Type of Grout i 0 Imoalion Approx. Depth n Eastern Surface Seal Installed by � G Repair Work Done U Type of Pump H.P. State Work Done Weil Destruction O Weil Diameter Sealing Material i Depth G Depth ; Filler Material i Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION XL REPAIR/ADDITION M DESTRUCTION 0 INo septic system permitted if public sewer is available within 200 loot.) installation will serve: Residence— Commercial K Other k Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: I s m AvretA- Water table depth a SEPTIC TANK O Type/Mfg �iJG Capacity1� No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal 1 Distance to nearest: Well � Foundation '� property Lina E LEACHING LINE ❑ No. & Len Length of lines 4✓0 .0-;1 Z a 9 f'" Total I�ngthlsi:a r �- FILTER BED f_1 Distance to nearest: Well _ _ _ Foundation 4L9F:!EL_?=12- Property Line 6 _ ' SEEPAGE PITS 11 Depth ��—) -Size J0 Y- Z �fD Z n �.Z� Number SUMPS LI Distance to nearest: Well 49�0_ Foundation21 _ Property Line 61 DISPOSAL PONDS ❑ i 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 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 ermpioy any person in such manner as to become subject to workman's compensation laws of Cablornia." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- r{� tion laws of California." tT The applicant t call f II ui d inspeplions, Complete drawing on reverse side. p SignedI Title: 57 u_T Data: FOR DEPARTMENT USE ONLY Application Accepted by Date D l7 Area ` Pit or Grout Inspection by Data Final Inspection by Dated%� Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 FEE INFO AMOUNT DUE r AMOUNT REMITTED CASH CK N RECEIVED 9Y DATE PERMIT N0. . EH 1`. IREN.t n Sr 81. D� Ql i C(J f d �� `r � �S)