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a APPLICATION. FOR PERAHT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL, HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCBTON, CA 95201 PERMIT EXPIRES 1 YEAS_FR_GDATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in co4liance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. i f , Job Address IS-4611 � 1f>_e"1rC/7 C,4/"p Rd' City r o w Lot Size/Acreage Owner's Name Z!ko r-a ( � -- Address S.O,t?e Phone kv 7ISdn• `t 50y a, +�L�' Ur'- License No. Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL,❑ P ..WELL REPLACEMENT-n DESTRUCTION ❑ Out of Service Well Irl - PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _r i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications I'l Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth t I Eastern Surface Seal installed by Repair Work Done U Type of Pump 1 =r-H.P. - State Work Qone.- Well Destruction '❑ Well Diameter Sealing Material 4 Depth. Depth biller Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION)d REPAIRIADDITION I I DESTRUCTION I] (No septic system permitted if public sewer is j available within 200l Installation will serve: Residence L_ .Commercial— Other + Number of living units: r Number of bedrooms Character of soil to a depth of k-test: 5,A)A IZ Water table depth h SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PL7.❑ Method of Disposal Distance to nearest: Well f �� Foundation Property Line 13" LEACHING LINE a W No.,& Length of lines 'A 910 � Total length/size /yo� FILTER BED ❑ Distance to nearest: Well 100`I' Foundation �� Property Line le i J6 1h�. SEEPAGE PITS I 1 Depth # Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I Q 1 hereby certify that I hove 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 cenifies 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 workmen's compensation laws of California."'Contractor's hiring or sub-contracting signature _certifies the following: "I eertify.that in.tfle.performance of the work.for'which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of Cslifornwa . ' --The applicant mu t call for all required inspections. Complete drawing on reverse side. Signed Title: t Date: f A x~~ Z DEPAR y_ Application Accepted by, at Ar + Ph or Grout Inspection by Date Final Inspection to Date Additional Comments: i Applicant - Return all copies to: San Joaquin County public Health Services Environmental Health Permit/Services 445 N San Joaquin, .P O Box 2009, 5tkn, CA 95201 w IN FE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE _ PERMIT'NO. EH 1.-2a i