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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I P O BOX 2009, STOCKTON, CA 95201 PERMIT EUIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) - r Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.s 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. I Job Address _ �(Q y s' f4! City 7X^1 Lot Size/Acreage Owner's Name f -1,r H-c1FFM Aa -T Address Am,5 Phone _A,; - 7 Phoneme 3RD! Contractor ACU !�. •T Address %/l/, 49-=L,Bt�7-i4 k/- License No. �� TYPE OF WELL/PUMP: 1 _ NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑Out o! Service Well Cl PUMP INSTALLATION O - SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n 01STANCE 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 Dia. of Well Excavation Dls. of Well Geeing LI ,Industrial ❑ Open Bottom ❑ Manteca ElvDomestic/ Private ❑ Gravel:Packe � t 0 Tracy Type of`Casrng_ Specifications I'I Ptiblic I I Irrigation Repair Work ,Done_. IJ Wall Destruction ❑ L C7 Othe . ", Approk. *'Oapth Type of Pump WaF,' Diameter ` t Depth I fl Delta I I Eastern Depth of Grout Seat Surface Saul Installed by H P • State Work Lone . Sealing Material i Depth Tiller Material i Depth Type of Grout TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I IND septic System permitted it public Sewer Is t : j available within 200 feel.l Installation will serve: Residence — iCommarcial Other ARk Number of living units: Number of! bedrooms -m—• Character of wo to a depth of 3 feet: } �-a Water table depth SEPTIC TANK 0 Type/Mfg ► r capacity"f No. Compartments Method of Disposal PKG. TREATMENT PLT, O . Distance to nearest: Well Foundation � Property lino LEACHING LINE No. R Length of line's e,� lid � Total length/site 2� � FILTER BED ❑ Distance to tnearest: Well. '7-V .Foundation 7 a Property Line r ic�0 Siie` �d..i,. Number SEEPAGE PITS t Depth ` SUMPS' LI Distance to,rtearest: Wen � Foundation`s Property Lina 1 .t I hereby certify that I have prepared this application,snd_ 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 of kt:tnsed agent's signature certifies the following: "1 cattily that in the performance of the work for which this permit is issued, I shall not ps nsation lswi.of California.- Contractor's hiring or sub -contracting signature employ any person in such m inneras to 1511CO 0 subject to workmen's corn eertltiss tow following: "I certify that in the performance of the work for which,this.permit is issued, I shsli employ persons subject to workman's compenss- tan laws of Canfornia."- The applicirit rnust call for all required Inspections. Complete drawing on reverse side, Signed X fo....+ y t6L_ -_ Title: '�scT Date: 19- 6i3 .FAR DEPARTMMOT USE ONLY A ppl icst Io n-1 c c epte d Ph or Grout Inspection by Adria al Comments: Data Data Area f!?Z-_Q Final Inspection Dat I Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, 5tkn, CA 95201 . II+ 13-24 (REV. I/ n es EH I4.2a FEE c AMOUNT DUE AMOUNT REMITTED N RECEIVED BY DATE PERMIT'NO. 1NF �fy file t