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7 j APPY;ICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES � 'YEAR FROM DATE ISSUED - (Complete in Triplicate) I Application is hereby made to Sane oaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. /� Job Address O A41 eN 9cf, City ar /v" Lot Size/Acreage Owner's Name Ci _q66. Oh/41Yd Address 1 Yb �• A;tV A, Rr _ _ Phone Contracts Aar e�' � �O Address,,( !' aowi j4 r•_P� License No.�yy"`�/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ 11 SYSTEM REPAIR C3 :» .�A QTHEA ❑.-\� Ndnftoring Well ❑ PUMP INSTALLATION ❑ _ P DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL~FLD•�'y PROP. LINE FOUNDATIO ---- 'AGRICULTURE WELL OTHER WELL f N PITS/SUMPS�$ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 L1 Industrial ❑ Open Bottom ; ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ^ [l Domestic lPrivate ❑ Gravel Pack " '"'"r ❑ Tracy Type of Casing_ ` Specifications- — I'1 Public Cl Other t! r Delta Depth of Grout Seal Type of'Grout I I Irrigation App(ox.�Depth I I Easterner .Sur4ace:Soul.installed by - f Repeir Work Clone LJ; Type of Pump H.P. Stato Work Done Well Destruction ❑ Well Diameter" Sealing Material & Depth '� O Depth Filler Material i Depth 4 1 r A ` TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION W DESTRUCTION I ) INo septic system permitted it public sewer is ; I" available within 200 feet.) Installation will serve: Residence Commercial^ Other r Number of livin units: Number of,bedrooms Character of soil to a depth of 3 feet: 5A1kd Water table depth SEPTIC TANK. © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ .•- Method of Disposal r Distance to nearest: Well Foundation Property Line j . . LEACHING LINE ❑ No. b Length of lines . Total length/size FILTER BED ❑ Distance 1; nearest: Well fi F ion Property Line + SEEPAGE PITS 11 Depth /40/ Size ls� Number SUMPS Jr Distance to nearest: Well _ I a o t Foundation ��• Property Line S f DISPOSAL PONDS ❑ l I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laves, and rules and regulations of the San Joaquin. County 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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." 1 .0 The applicant Myet call for all required inspections. Complete drawing on reverse side.4 Signed + Title: Date: s[ FOR DEPARTMENT USE ONLY C Area Application Accepted by Date_ /+ ` Pit or Grout Inspection by _ Data Final Inspection by ate �Z 7 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services fl .I Environmental Health Permit/Services 445.N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE J AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•NO. INF.O/� // ,r..1 ♦L� /9 ,mfr F��+, A-0-7- . EH 13.24(AEV.ties) Bre /[ �` �` !' ` `� + Gip ,2 �� slv EH fl•?d