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S 'y 9 �y'a .fir a h�... tAPPLICATION FOR PERMIT orf, � t ,.i. . 2' ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 (Complete in Triplicate) Application is hereby made,to San Joaquin 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. Jab Address to r� /j1�J25E�y City Lot Size/Acreage „x.20 X Is/1 Owner's Name SANIES �77f&X-S •- Address Phone Contractor. FLOY2 E. 4/a2 D Address y .4�E�BE.�%AWC.- License No. Y�6 ._.Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE 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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 0 Public (-1 Other 0 Delta _ Depth of Grout Seal Type of Grout Ci Irnpation ....... Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction Cl Well Diameter Sealing Material i Depth Depth Filler Material i Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATION I) '.REPAIR/ADDITION DESTRUCTION CI (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence v Commercial Other Number of living units: Number of bedrooms 3- Character of soil to a depth of 3 feet: _ -e Water table depth SEPTIC TANK ❑ Type/Mfg C X II7—//ti G ... Capacity No. Compartments PKG. TREATMENT PLT. ❑ T Method of Disposal Distance to nearest:' ' Welt 'Foundation' Pioperty Line LEACHING LINE No. 8 Length of lines / `�d r _ Total length/size i FILTER BED 13 Distance to nearest: Well Foundation Zj2 / _ Property Line :W _ SEEPAGE PITS I Depth 7--V- Sire 33 , Number � SUMPS Lt Distance to nearest: Well If Foundation lite Property Line '249 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 fallowing: "I certify 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 workmen's compensation laws of Calilornia." 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- tion laws of California." The applicant must coli for all required inspectionsomplete drawing on. reverse side.- - - _ -- Signed Title: �� _ _._ Date- FOR'-DEPARTMENT ate:FOR-DEPARTMENT USE ONLY Application Accepted by Dates L Area Z,� M1 Pit Grout Inspection byama 1_ _ _ Date L^ZZ Final Inspection by Date E Additional Comments: r Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 Box 2009, STOCKTON, CA 95201 FEE INFO {AMOUNT DUE AMOUNT/REMITTED CA$H RECEIVED BY ^DATE PERMI7'N/O. EH13.241REV.1/X51 Qg t f —D1rf] S EH 114,26 l`l F