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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 EXP I RES �1 YEU FRPM DATE ISSUED (Complete in Triplicate) Y®Z —j(,© —0? /17S''iG sSo^�"�p1J z °8 { IA4v 7 Application ie hereby made' &sa`Joaquin County for's permit to construct and/or install the work herein described. This ' application ie made in coWlianceivith San Joaquin County Ordinance No. 5�4 and 1862 end the Rules and Regulations of Elan Joaquin County Public Health Services. Job Address S N Ta %N s'v®9' �L� Lv A-a-8 5Ry. 2 Cityr� -_ Lot Size/Acreage (� Owner's Name A.r p Address Phone t M j j. License No., Phone Contractor 4 Soy Address M172 19LV dM fv` Service Well 0 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EI �� DESTRUCTION Ll Out ofOut Well © 1 PUMP INSTALLATION ❑w -'�"---SYSTEM"SYSTEM REPAIR"Cl OTHER C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� O —_ INT-ENDED-b'SE—" !TYPE R0BL'EfiAi4REA CONSfAUICTld1` P icwtoATtOIHS'" Q 4 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation ' - Dia. of Weil Casing Cl Domestic/Private ❑ Gravel Pack 2 --.0,Tracy. Type of Casing_ Specifications s III Public Cl-Other-- # fl better Depth of Grout Seal Type of Grout h I I Irrigation Approx.i Depth I I Eastern �Surf ace Saul 1'nstalled by ! Repair Work Done LJ .Y Type of Pump H.P. Stat4'Work Done _ Well Destruction ❑ Well Diameter Sealing ttaterial i Depth ! i Depth ! biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION Irl DESTRUCTION I I (Nosepttic system m permitted it public sewer isavailable p- Installation will serve: Residence J✓ Commercial— Other k Number of living units: If Number of bedrooms - V Character of roll to a depth of 3 feet, r'/A ,- Water table depth i SEPTIC TANK. D TypalMfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal J t ' Distance to nearest: Well Foundation � A Property Line `� I 9 LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line r } i SEEPAGE PITS I I Depth `f Sire y f _ Number r g. SUMPS 0 Distance to nearest: Well�— Foundation Property Line DISPOSAL PONDS ❑ .. - 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, 1 shell not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the following: 111 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 mu call for all required inspections. Complete drawing on reverse side. _— ! Spm Title: Date: FOR DEPARTMENT USE ONLY � Date Area Application Accepted by fflA1111 Mau _`� 3 r1 Pit or Grout Inspection by Date Final Inspection by Date G�J3 Additional Comments: r I Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009; Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMIT'No. AAI CASH INFO A �/ . EH 13.24 IAEV.riitsi IxS r Gt I!� 4a2�q� EH 14.20 11