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APPLICATION Applicant - Return all copies to: Szn Joaquin County Public H th Services Ezvironmental Health Permit/Services 445 N. San Joaquin, P.O. Box 388, Stockton, CA 95201- en.r, Pt ID SAN JO QUIN COUNTY PUBLIC HEALTH SERVICES NVIRONMENTAL HEALTH DIVISION 44 N SAN JOAQUIN, PHONE (209) 469-3420 0 BOX 388, STOCKTON, CA 95201-0388 Application is hereby made to San Joaquin County for a peril to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Development Title Section 9-1110.3 and Se...-ram 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. I hereby certify that I have prepared this application anc1 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 true f ollowing: "I certify that in the performance of the work for which this permit is issued, I shall not FN employ any person in such manner as to become suolect to workmen'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 snail employ persons subject to workmen's compensa- tion laws of California." The applicant must call for all required inspections Complete drawing on rev rse side. Date Signed Title: FOR DEPARTMENT USE ONLY Application Accepted by Pit Of Grout Inspection by Date Final Inspection by Additional Comments: ./Wa/".5. ,57-ti/1/ FEE AMOUNT DUE AMOLMT REMITTED CK i CASH RECEIVED BY --.-------SAIE . ---' PEHM1-1-NO. (s-2? E7 ig/6 /let P /6/9/ 6e1,9100C EH 13.24 (REV / 5) EH icze FAC # INV# rPr'EiVEL AUG 1 6 1924 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r:NVINONIMENT4 HEALTH PERMIT/SERVICES (Complete in Triplicate) osefrn Marjorie_ rady Address t e. b , -hone Owner's Name CO) , 1 .1_,, i_ _i i Contractor NI I lunc_ii Dr.i k i vvy-- Address n 2>OX• 225} R(.41'010 601(tilekicense No. Phone 1J6r1C2 1S5S' TYPE OF WELL/PUMP: NEW WELL , • WELL REPLACEMENT El DESTRUCTION CI Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR E) OTHER 0 Monitoring Well )if DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRCBLEM AREA CONSTRUCTION SPECIFICATIONS // C-1 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation gi 1 Dia. of Well Casing .. CI Domestic/Private Pack Tracy Type of Casing Pvc., Specifications 7(Gravel .0 I'l Public (.1 Other 17 Delta Depth of Grout Seal I 3 1 Type of Grout Cerne. , I Irrigation * A p pr o x Depth I I Eastern Surface Seal Installed by .35' . Repair Work Done 1_3 Type of Pump H P State Work Dgne Repair Well Destruction 0 Well Diameter Sealing Material & Depth C.t.Thfivd- to ..,.A.1... i 8" i Depth Filler Material & Depth Si] ie. Cc, ...Sailart- -rdle",120e-K--./ 8"f9/ TYPE OF SEPTIC WORK: NEW INSTALLATION ' REPAIR/ADDITION i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercai Other _ Number of living units: Number of bedroor-s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Weil Founaation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 City 5-Foczni_ Lot Size/Acreage