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APPLICATION FOR PERMIT { SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PCZ X)0 Zo_13 H-357 P 0 BOX 2009, STOCKTON, CA 95201 F->F15r urs►t�r.y !-j-. 5 PERMIT EXPIRES 1 YEAR FROM DATE I8-82ED (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. o � Job Address `70 ��r J/L 'tfVf©IV 210, City m Lot Size/Acreage Owner's Name /1 jf�N775G1�}`. u s Address BX 13 Z ` M 7 EC-f4 Phone 2-5 3 Z-S 2- Contractor fzG I,UF�ec�e*1Address 7u ZS "'nY -�rr*� RT 6 — icense No. Sl Z6e Phone 9S—),3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ e 1 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER J9- DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES DISPOSAL FLD._ aA912 i►rc FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED ELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom Cl Manteca Oia. of Well Excavation Gia. OF Well e OM ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Speeiliestionir ILI q,01 I 11 Public f_1 Other Fl Delta Depth of Grout Seal - ,Iype-at- r t C>&-" t 1 I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by d Lr.J 1;1,ZCrV Type of Pumpf f Repair Work Done U T ' r H.A. State Work Done� wl� B�-�•JL.c ,Well Destruction 0 Well Diameter Sealing Material i Depth �1 ! It 4 Depth biller Material A Depth P-bl STYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION [ I (No se lic system rmitted if . P y Ae public sewer is � available within 200 feet.! \V} ' X. installation will serve; Residence T,.�Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest; Well Foundation Property Line I LEACHING LINE C1 No. IIr Length of lines Total length/size FILTER BED .0- Distance to nearest. Well Foundation Property Line I I SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 1 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 sub-contracting signature candies the following: "I certify that in the performance of the work for which this permit is issued, I Obeli employ persons subject to workman's compansa- tion Iowa of California." ti f The applicant t call for all r uired insPections. Complete drawing on reverse side. Srgrled Title: ti-6 6 7�-6/S Date: 6 _/S-7-7Z- F R PARTMENT USE ONLY Application Accepted byIV Data � � � Area Pit a Grout Inspection by Datf Final Inspection b Dated Additional Comments• - Applicant - Return all copies to: San Joaquin County Public Health Services I Environmental Health Permit/Services fw 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 w t _ _ FEE. CK INFO AMOUNT DUE AMQUNT REMITTED RECEIVED BY DA ' 'PERMIT'NO. Ek 11.10 r