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i. APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468--8-W3`),;-0 PERMITEXPIRES 1-YEAR E I�� (Complete in Triplicate) Application is hereby made,to Sea Joaquin County for a permit to construct and/or install the work herein described. This E 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. City Lot Size/Acreage Job Address 2S'�3 s`, �/��'O� �A Owner's Name . 'Toy Address Z^� Q '_CLt1 _ P-0 . 60X 6 R! Phone 835'- qO qC, t Contractor SELF_ Address License No. Phone �� _.,_ TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT T.1 DESTRUCTION 0 Out of Service well ❑ _OTHER,❑_ Monitoring Well PUMP,INS.T.ALLATION-❑--"--- -- ..— SYSTEM REPAIR-C7r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE e _- - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L) Domestic/Private ❑ Gravel Pack ❑ Tracy .- Type of Casing Specifications M Public la Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irrigation Approx. Depth , ❑ Eastern 5oriace Seal Installed by Repair Work Done U Type of Pump H.P. •' ° State Work Done- IJI Seaiiag Material i Depth ` Well Destruction © Well Diameter `- # Depth •T' f„I t Filler.Material i Depths UGt TYPE OF SEPTIC WORK: NEW.INSTAL LAIIONX REPAIRlADDITION 0 `DESTRUCTION CI (No-septic-sysiem permitted if public sewer is available within,200 feet.) , installation will serve: Residence Commercial Other t-_t ; Number of living units: Number of bedrooms - t Character of soil to a depth of 3 feel ' Water,tableldepth SEPTIC TANK. O Type/Mfg •Capacity No. Compartments y PKG. TREATMENT PLT. ❑ t ) Method of Disposal df Distance to nearest: arest: Well Foundation ' Property Line L c t r LEACHING LINE ❑ No. &-Length of lines Total length/sire a� FILTER BED Cl Distance to nearest: r Well Q Foundation Property Line SEEPAGE PITS I l,f Depth Size t Number + � f - SUMPS CI Distance to nearest: Well f `Foundation Property Line DISPOSAL PONDS /❑ •”"� ' a I hereby certify that,I have pfepared'this application and that thelwork will'be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County i - ; 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 of subcontracting 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- tion laws of Cafifornia." P The applicant must c il'far alb;required inspections. Complete drawing on reverse side, r Date. Signed Title:- � - --T� -- �► JD 4 h ef FOR DEPARTMENT USE ONLY Application Accepted by Data 9 1 Area Z L Pal or Grout Inspection by r Date Final Inspection byDate Z Additional Comments: z - Applicantiteturn all copiee to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES !,"—';"EXVIRONilENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2006, STOCXTON, CA D5241 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO EH 17.2 TREY.1/"5) 11,Lk, m0 nasi -Z_ EH 7426