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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV I RONMF.NTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE S (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 coailiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 9`/3 2— C i City _577.�'J Lot Size/Acreage J Q� Owner's Name -D 67/J /h u4-1—_ Address S Phone 196^2- -4-0 I EL Contractor TF40KD W410i> Address _7./I✓, PP 54,4icense No. Phone 14 4'391 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well O 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 0 Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public F1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation+0 A pprox. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 7REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 Ieet.1 Installation will serve: Residence 1/' Commercial_ Other Number of living units: ___L Number of bedrooms _Z Character of soil to a depth of 3 feet: 1"A Water table depth SEPTIC TANK ❑ Type/Mfg Capacity__I_�E_00 No. Compartments " PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well 4°� ` Foundation —_ Property Line /67 LEACHING LINE No. & Length of lines Total length/size 7 d FILTER BED ❑ Distance to nearest: Well OO Foundation f O r Property Line /�r SEEPAGE PITS 14' Depth Z'S r Size ��` Co " Number 'Z, SUMPS Ll Distance to nearest: Well 5-0 ` Foundation__ �4 ' Property Line ^/.S_' DISPOSAL PONDS ❑ I hereby certify that 1 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 empioy 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 certify that in the performance of the work for which this permit is issued,1 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 Title. Dote: _ 3 S—9.3,,,,,_„_ FOR DEPARTMENT USE ONLY Application Accepted by Data 3 Area L Pit or Grout Inspection byDate Final Inspection by Date 244? Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services I� 445 N San Joaquin, P O Box 2009, Stkn, CA 95241 NF AMOUNT OUE AMOUNT REMITTED CA$ RECEIVED BY !� O E PERMIT'NO. • EH 13.24 411EV,i i n 5) ”" ` EH 14.21 ` i