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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 PFM12: EXPIRES_ X YEAR FROM DATE ISSN , 'viLNTAL HEALTH (Complete in Triplicate) t � N�4 /'SERVICES 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 co4llance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. APA/ ON-cu-- 11 Job Address GZL /f+ Q S/f d.V7Fr2 Dir uE City Src�r;TCA_) Let Site/Acreage , q Owner's Name IVOR MAe �r.x- .^ Address*fQ. ,-, 21 401 7 5;4-,R -44,"To Phonal ?. 5Ze C0nlractor5P&: +�T2QEy a2PATIOr.} Address 2& Sr'` 't'!e -" j 4r-- License No.%5 12 2,G Phone �GS`-DTIC TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Moaitaing hell U DISTANCE TO NEAREST: SEPTIC TANK d_ SEWER LINES Zoo- DISPOSAL FCD.192,4 PROP. f NE _-/0 s FOUNDATION -LOL— AGRICULTURE WELL IYa OTHER WELL �,s.�`. PITS/SUMPS ffzd INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f-7 Industrial ❑ Open Bottom ❑ Manteca Oia. of Well Excavation " Dia, of Well Casing olic. Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingt\jQn! __ Specilications 0 Public 0 Other ❑ Delta Depth of Grout Seal 15oRr Type of Grout Cl lrrigalion 3'�Approx. Depth ❑ Eastern Surface Soul Installdd by Repair Work Done U Type of Pump H.P. Slate Work Done _ t Wall Destruction ❑ Well Diameter Sealing haterial i Depth Vwi Depth Filler Material i Depth 1 TYPE OF SEPTIC WORK: NEW'INSTALLATION ❑ REPAIRIAODITION Ll DESTRUCTION CJ INo septic system permitted if public sdwer is available within 200 fast.) Installation will serve: Residence— Commercial_„_ Other a Number of living units: Number of bedrooms Character of soil to a depth of 3 fest: Water table depth A ,if SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Propeny Line 5► ,i LEACHING LINE Q No. ii Length of lines Total length/sire FILTER BED n Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Sire _ Number SUMPS Ll 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 fallowing: "I certily that'in the performance of the work for which this permit is issued, I shall not employ any person in such manner■s 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 poison&subject to workman's compensa-• tion laws of California." The applicant A;sjc& ar qui inspa ions. Complete drawing on reverse side. ,j� a Signed Title: i,_��f! T Date: lflm, M. 1,70 FOR DEPARTMENY USE ONLY I Application Accepted by -6%-f [ I Date Area Ci Z- Pit or Grout inspection by 7 Date f Final Inspection by Date Additional Comments: -y _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES + �� 445 N SAN JOAQUIN, P 0 A 009, STOCKTON, CA 95201FEE ] INFO AMOUNT DUE AMOU/NT REMITTED CK RECEIVED BY OATE PERMIT N0. EH 14.26