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T APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 7 � ., ., r t a ENVIRONMENTAL HEALTH DIVISION � .�.,. ;..:�� , C. P O BOX 2009, STOCKTON, CA 95201 APR 19' n (209) 468-3447 91 EI'IVI RONMENIITAC. HEALTH � y PERMIT/SERVICES y r (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This i application to made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules &ad Regulations of San Joaquin County Public Health Services. �rf�C.�_�_ Got Size/Acreage i1 n �[,no�• I Job Address I05 1 S' I-1ac Aa%1%,,r B"tA. City — { C Phone �(LS 4Z(o' N L � s� �.I Address tr'O• �� SZ S Z P1ec.skn�n - Owner's Name onea84566 i CA Phone"�i5 �q8�b fir+„ �, S ec.Sr��rs s Address 3 �c+e�,ece g�'r`I`' Pac�.ece License No. - i Contractor pESTRUCTION O out of Service Well C1 WELL. REPLACEMENT n Monitoring Well TYPE OF WELL/PUMP: . NEW WELL ❑ SYSTEM REPAIR 0 OTHER X PUMP INSTALLATION ❑ 2-6- _W ,i:• � DISPOSAL FLD.U9�n PROP. LINE 2 DISTANCE TO NEAREST: SEPTIC TANK ttnlCnarJ�n _ SEWER LINES -- }xaao '. PITS/SUMPS QacA-wtk FOUNDATION Unk^"`��- AGRICULTURE WELL uAL4014n OTHER WELL -T INTENDED USE- TYPE OF WELL PROBLEM fM AREA-.=C-ONST UC—TION-SPEC-SPEC -ATIONS= Oo�� Dia. of Well Casing Industrial [3Open Bottom ❑ Manteca Dia. of Well Excavation 0041 Specifications ❑ Gravel Pack �Tracy Type of Casing U Domestic/Private Type of Grout ❑ pelta Depth of Grout Sea! n�^� CI Public D(Other t CI Irrigation ab f Approx,Depth Ll Eastern Surface Seal installed by A SI to Work Done _ Repair Work Done {]. Type of Pump °nom — H.P. Material h Depth rta J 10� ,� Well Diameter NA- Sealing r Will Destruction Filler Material & Depth Depth TYPE Of SEPTIC WORK: NEW INSTALLATION W REPAIRlApOITION C3 DESTRUCTION CI afvailabe within 200 feet-t11 if public sewer is � Installation will serve: Residence Commercial Other 1' Number of living units: Number of bedrooms Water table depth Character of soft to a depth of 3 feel:T No. Compartments SEPTIC TANK 0 Type/Mfg Capacity— _ Method of Disposal PKG. TREATMENT PLT.❑ xProperty Line ! Distance.to nearest: Well Foundation o it Total length/size LEACHING LINE Cl No. & Length of lines Property Line FILTER BED n Distance to nearest: WeN Foundation______�— r Number SEEPAGE PITS 11 Depth Size SUMPS LI Distance to nearest: Well Foundation— Property Lina DISPOSAL PONDS ❑ 1 - E ill be done in accordance with San Joaquin county-ordinances:'state lbv�rs"anda hereby-certify that I have prepared this-application and that the-work wC rules and regulations of the San Joaquin County 1 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 she not employ any person in such rnanner 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 shall employ persons subject to workman's compensa- lion laws of California." Q The applican ust call for a red inspections, Complete drawing on reverse side. Title- •t r.nnno.a Ll C—n r Date: ` _q 1 Signed y T FOR DEPARTMENT USE ONLY ...__ a Data �i Area Application Accepted by Pit or Grout Inspection by Is--_—�` Final Inspection by Date Additional Comments: �r �' 113�1�5 1S9U4..kN z_� t Applicant - Return all copies to, BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES l 44TH HEALTH DIVISION PERMIT/SERVICES SAN JOAQUIN, 0 BOX 2009, S 5TUCKTON, CA 852017• FEECK EC INFO By DATE PERMIT'NO. INFO (�Ap�M}pOUNT DUE AMOUNT REMITfE4 CASH �Q Q ��] EH 13-24I11EV.1/MSI F ri`� ' EN 71.26 V