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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468--3447 REMIT EXPIRES I YEAR EM DATE ISSUED (Complete in Triplicate) Application is hereby taade,to San Josquin County for a Permit to construct and/or install the work 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 4-3�tj 4, 'p_,T/TWS G'/��L� City S7X// Lot 'Size/Acreage Ste►� Owner's NameZ4W_,,9J_5 l-/4fE Address . .,,...... . .,,,,_..-_—•— Phone - fir/ S i 4 Contractor^Fl-©," Address `7�t/. AAc e,Bc�r eV License No. 4-24_y'76 Phone 0,64' -3g7/ TYPE OF WELL/PUMP: NEW WELL •._ WELL.REPLACEMENT C_l DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK: EWER LINES .DISPOSAL FLD. PROP. LINE 'F6 U'NDATIO1N'__.6zy A (CULTURE WELL _ "-OTHER,'WELL. PITS/SUMPS., .. . INTENDED USE TYPE OF WELL PROBLEM A ICO RUCTION SPECIFICATIONS' !� Industrial ❑ Open Bottom ' ., ❑ Manteca is. of Well Excavation Dia. of Well Casing ' " wM— U Domestic/Private Ll Gravel Pack ❑ Tracy �. ype of Casing Specifications M Public is Other ��© De k De h.of Grout Seal - °' -Type of Grout s Gl Irrigation, _.Approxi Depth astern, Su Seyl Installed by Repair Work Done L] Type of Pump H`l?-^ ! State Work Done ._ t Well Destruction D Wet i Diamet SealingiMaterial Dept)✓.. •--�` �1 - + Depth Fillerrlfaterial i De 'h TYPE OF SEPTIC WORK: NEW INSTALLATION v REPAIR/ADDITION DESTRUCTION G (No septic system permitted'if public sewer is t ` available within 200 feet.) Installation will serve: Residence Commercial therGfDn��?r�nJir� Number of living units: �. Numbei of bedroomsi S Character of soil to a depth of 3 fest: s � A Water table depth +� SEPTIC TANK ❑ Type/Mfg - _� _ Ca `cli ZlvC� 'I Z pa y` No. Compartments PKG. TREATMENT PLT. ❑ Method 61 Disposal Distance to nearest: Well_ Foundation /y Property Line—Z- LEACHING LINE Np. S Length of lines r Total length/size i' .!?a FILTER BED fl Distance to nearest: Well Foundation . .,�0/ Property Line` r .� � r ✓f SEEPAGE PITS i Depth Size 4--2- Number __3 1 1 i SUMPS LI Distance to nearest: Well_�VIA Foundation 1�0 0 r Property Line Z�r DISPOSAL PONDS ❑ I s` I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin County , t Home owner or licensed agent's signature certifies the following: -.I certity 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 or sub-contracting signature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compansa- r tlon laws of California." 1- _ ! The applicant must call for all required inspections. mpiete drawing on reverse side. I Signed cTitle: _ ( .'"- .- :.... Date: i , FO DEPARTMENT USE ONLY i Application Accepted byDaterl�gp 463&Af��a .� Cl k Area Pit or Grout Inspection by Date Final Inspection by Date Z$ Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOR 2008, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8V DANE J /�PERMIT'NO. . EH 13.24MEV.IINS) 11 w � ' 0 i3COZ MR 21 {1 LEH.4.2e 111