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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468—'3447 ZEMIT ESBIRES „IYEAR rROM DAZE ISSUED (Complete in Triplicate) Application is hereby made,to $an 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 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 93 Cv z E • 4/&yZ> !r/A.eD !Q/CI City hza 6 7! M Lot Size/Acreage 1-®4v,�v /00 Owner's Name 0-04-07”"—'Al 5eR72A Address 3979 W_"h0A1 IJAZ/, Phone A. vE,err�dec q.,�sra Contractor EL19„J�P_ 1r/a_,a Address 7 Al, License No. #fes ?t__ _Phone =3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C.7 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [� 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications M Public CI Other 13 Delta Depth of Grout Seal Type of Grout 0 Irrigation ,_._.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump N.P. State Work Done_ Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION❑ L REPAIR/ADDITION X DESTRUCTION Cl iNo septic system permitted if public sewer is available within 200 fee t.I Installation will terve: Residence ✓ Commercial-__.,, Other �t7 P�AGC 7-741 � l.) Number of living units: —4-- Number of bedrooms _�_ Character of soil to a depth of 3 feet: __. 5- dLD Z LOA,,A Water table depth 4th SEPTIC TANK TYPO/Mfg Capacity__I y924 No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal r Distance to nearest: Weil Foundation /D Property Line 30 r LEACHfNG LINE 0 No. & Length of lines 7-J Al Total length/size FILTER BED LI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1:1 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 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 certifies the following: "I certify that in the Wofmance 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 call for all required inspections. Complete drawing on reverse side. Signed Title: 61-el-I Date: 7---10- Qo FOR DEPARTMENT USE OtNLY Application Accepted by Date �Z e Area Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA SH RECEfVED 9Y DATE PERMIT'NO. . EN t`, ir+EV, I/s SI [tam f)� I`'J� �� V�V �� V