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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 46$-34473LLO V �' E;. (Complete is Triplicate) LL *n�� Application is hereby mads to Sao Joaquin County for a permit to construct and/or install-xhe vork herein feecr2'ded. This application is mads"in compliance vith San Joaquin County.Ordinance APA) 149 and 1862 and the Rules and Regu4tiona. of,,San Pr Joaquin County Public Health Services, P OT4-0 S*-Z f t_a ti Job Address CityS`��=�Ti?N Lot Size/Acreage 14-,J Owner's Name 4mAsetraiij_�awic¢.5 Address 51 o ,TdA[J�o'.). �T_ Phone T ContractO-PIS'rJUM FxPLnP Address 2,625-M E S1: SMCKMLL License No.5l22_1n8 Phone .5 a 71Z TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION O Out of Service well ❑ r� ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER tZ20nit rin Well DISTANCE TO NEAREST. SEPTIC TANK -SCC= SEWER LINES /�� DISPOSAL FLO. V1,4- PROP. LINE J� FOUNDATION AGRICULTURE WELL &ZA— OTHER WELL-Ve!f� PITS/SUMPS ,yzef r V• INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Ole. of Wall Excavation /O Dia. of Well Casing lyoue . ((Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing----&oq Specifications Q Public if Other ❑ Delta Depth of Grout Seal ! 1VZFACE Type of Grout CJ lrrioation Approx. Depth ❑ Eastern Sudalt:s Saul Installed by_00NTEAC carr- ' Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing lkterial 4 Depth Depth Filler tfaterial 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION CI DESTRUCTION C1 (No seplic system permitted if public sewer is available within 200 #eat.} Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg - _._ Capacity No. Compartments PKG. TREATMENT PLT.Q f Method of Disposal Distance to nearest; Well Foundation Property Line LEACHING LINE 0 No. $ Length of lines Total length/size � FILTER BED Cl Distance to nearest: Well Foundation Property Line -C !I 1 SEEPAGE PITS It Depth Si1e (Z),Number Vt SUMPS LI Distance to nearest: Well . Foundation Property Line C DISPOSAL PONDS C3 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and ~ rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that In the perlormance of the work for which this permit is issued, 1 shall not employ any parson in such manner as to become subject to-workman's compensation laws of California." Contractors hiring or subcontracting 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 laws of Cslifornla." . The applicant t call Of ell r r i' speetions Complete drawing on reverse side. Signed X. Title' Date:// I/1ey FOR DEPARTMENT USE ONLY v Application Accepted by Date 1 �'3/ ( Z Area ��t� L 'e). Pit or Grout Inspsction by Date ` Z Final Inspection by fA la,2w. Date �? Addltlonal Comments; /? •^ Applicant - Return all copies to; SAN OAQUIN COUNTY PUBLIC HEALTH SERVICES r E' ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES r� 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO �j C H RECEIVED BY j DATE PERMIT'NO. • tai u•i�veto.�i e u - �� Q� t�C � 35�j� G�d'"� d( L 5�Gi 4' �"�r�