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APPLICATION FOR PERMIT G SAN iOAQUIN COUNTY PUBLIC HEALTH `6ERVICES 1vu / rj ENVIRONMENTAL HEALTH DIVISION Act- All-An1 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE 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 in ode is compliance vlth Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ��)) f C 1 C Job Address "C/03 �G � LI ULJ h�77 jV'^ City /�'�"� Lot Size/Acreage lain /X1 Z-O ��,✓��t `E7,� / f -Ic Cc.wa,.t.c hcyy.ctlS v_ kv�w.A �hpnc;f �— 9 00 Owner's Name`�e�iO �� •Lc�CC-r) �..C• Address CzyG v L� u7�T 103-7 A./r cl zCa G C Hwy. �pI Contractor /� ��+,t=`'� 1v�C• Address Cr.. Gc.r j C.A J License No. y'34. {3 Pn e E71—2 s7 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ 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 /t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation rv�cltit'J Dia. 01 Well Casing (1 CI Domestic/Private XGravol Pack ❑ Tracy Type of Casing_ V C Specifications I'1 Public Fl Other (l Delta Depth of Grout Seal "' / t Type of Grout y`e C&v i" �� I 1 Irrigation ,J=/�� Appiox. Depth I I Eastern Surface Sail Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ [� Well Oestruction O Well Diameter Sealing Material i Depth ct Depth Tiller Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No Septic system permitted it public sewer is available within 200 fee[.) Installation will serve: Residence _ Commercial_ Other \` Number of Irving units: _ Number of bedrooms Character of wil to a depth of 3 feec Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to maresD Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby canity 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 Sen Joaquin County Home owner or licensed agent's signature cantles 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compense- tion laws of California." The applicannt�must call for all required ,insplectro/ga. Complete drawing on reverse side. Spired xX/•ve�vCh, �. 0// --Uk....t Title: E-cT �';2C�C.q r�T Date: J FOR DEPARTMENT USE ONLY p r Application Accepted by net d �Z_ Araa 3G n Pit or Grout Inspection by Date Final Inspection by Date 1 , Additional Comments: Applicant - Return all copies to: San J quin County Public Health Services �V Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stan, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK I RECEIVED gV DATE PERMIT NO. FO 9 CAA/SH . EN ,).Z.tREV.I,.SIM EH 14M