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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 P ES I. i,TEISSUED (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 cot;pliance;with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address , S1 -�Z Lh -A L=Z,6 C_' T City 577<A Lot Size/Acreage Owner's Name &9&7- f l!/ /ZR -- Address Phone Contractor FLS f2 k3[ ay -Address 7-Af,-�D �-B. -Ari. -- 4 ,�,�� License No.�,Phone -597 TYPE OF WELL/PUMP. NEW WELL C1 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 Well Monitoring PUMP INSTALLATtON_C7-- -� -:..-..-ter.SYSTEM REPA3R C7 OTHER C7 C7 n+y DISTANCE TO NEAREST: SEPTIC TANK �* SEWER-LINES DISPOSAL FLD. PROP. LINE UTJ FOUNDATION - ,AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C"] Industrial ❑ Open Bottom ©_Manteca„. Dia. of Well Excavation Dia. of Well Casing U Domestic/Private D Gravel Pack n Tracy 'v Type of Casing Specifications ID Public I'll Other ❑ DeltaDepth of Grout Seal Type of Grout Ci Irrioation Approx. Depth ❑ Eastern Surface Saul Installed by Repair Work Done U Type of Pump —"H.P. State Work Done Welt Destruction ❑ Well Diameters 'Sealing Material i Depth Y Depth f Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION L7 DESTRUCTION CI (No septic system permitted if public sewer is J i available within 200 leet.l Q Installation will server Residence_r A, Commercial_ Other 4BA41)>aA1 z-_X1s7-116. 7-XWe r Number of living units: __L Number of bedrooms Z Character of soil to a depth of 3 feet: ____ __C:4_A V „ , —Water table depth SEPTIC TANK. Er-Typo/Mfg i C- jn�,V-L - Capacity d No. Compartments -A— PKG. PKG. TREATMENT PLT, O Method of Disposal s Distance to nearest: Well _ Foundation Property Line -� i LEACHING LINE No. & Length of lines Total length/size FILTER BED 171 Distance to nearest; Well Foundation Property Line SEEPAGE PITS 11 Depth S -Si:eK - -- Number .�- SUMPS Distance to nearest., Well Lv� Foundation for Property Line S r DISPOSAL PONDS 0 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 fotlowing: "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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Iowa of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed 7� _._._.._ Title: t.� . ,. Date: - ;)-a -9 i DEPARTMENT USE ONLY Application Accepted by _. 0► . ,�t+ .Gl.e Date �-�� Area Pit or Grout Inspection by Date Final-Inspection by Data Vi r - --_ 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 OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, EH 13-24 IREV.1 I M 51t07[ '] Z - )� Q EH 7426 O G `