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J M f APPLICATION. FOR PERMIT SAN Ju, QUIN COUNTY PUBLIC HEALTH S�AVICES I ENVIRONMENTAL HEALTH DIVISION 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 end/ or install the vork herein described . This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services . ` 1�� 1. Job Addressnn ��o AignY .1 -1Z• ':.zTc10 Sireft CityS tuAL•+ E% n Lot Size/Acreage Owner's Name 1-t1� �t� � :Y [U; ( � l.f?.!'�Address 7 TL Oil Oil Phone Contractor )" _ I a Address Y' bd L�c:X (9rc 7 License No, w Z Phone TYPE OF WELL/ PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 OTHER ❑ Nonitoring Well O DISTANCE TO NEAREST: SEPTIC TANK AIA SEWER LINES Z�W DISPOSAL FLD.4&&. PROP. LINE &A FOUNDATION AGRICULTURE WELL OTHER WELL 'Sf QQ PITS/ SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation W 1 nt- h Dia. of Well Casing X Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Duc Specifications ('I Public F1 Other ADelta Depth of Grout Seal 5' ;L -IFeCi- Type of Grote Ar e I I Irrigation _ Approx. Depth I I Eastern Surfs" Seal Installed by .I)rt ) 1C.oO-1 Repair Work Done U Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material a Depth O Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR /ADDITION I I DESTRUCTION I I Wo septic system permitted if pr available within 2001eet. 1 IRECEIVE SI I Installation serve: Residence _ Commercial _ Other G • 1G Number of living units: _ Number of bedrooms N OV 0 9 19 2 Clwactas of wil to a depth of 7 fat: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments SAN- JOAAUIN CO 1N�`Y� PKG. TREATMENT PLT. ❑ Method of Dispos� VIS: D Distance to nearest: Well Foundation Property Lim LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lim SEEPAGE PITS ( I Depth Sue Number SUMPS LI Distance to neatest: 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 mnifies the following: "I certify that in the perlormance 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 taws of California. " Contractof s hiring or sub-contracting signature certifies the following: "I cenify 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 Calif orn .' The applicant etc i inaprrdbna. Complete drawing on'"r7everse side. r Signed Title: Y✓ntea-4- Ma-ta1 � , Date: Z `1 FOR DEPARTMENT USE ONLY .. Application Accepted by QXZ Date II IO / y Area `GF Ph or Grout Inspection by Date /! /v 4 'v Final Impaction by f - - 0�! Additional Comments: r "u"' -I T Applicant - Re all copies to : San Joaquin County Public Health Services ! I Environmental Health Permit/Services � 0 445 N Sas Joaquin , P O Box 2009 , Stka , CA 95201 INFO AMOUNT DUE AMOUNT REM/MED CASH RECEIVED BY DATE PERRMIT' NO. . EN N OW (REV, r / e !r � F. U ( a�', U l�'/D P� !j •3 EHOW 11•la