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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 PERMIT EXPIRES 1 YEAR PROM DATE ISSUED (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 ccmitiliance with Ban Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. �?.� Job Address t may/ Ciryp��l, „1 Lot Size/Acreage Owner's Nama -� A4klresz 9355 . tf>, l/�ki, w,�ono y� 7 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gtavol Pack ❑ Tracy Type of Casing Specifications — M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth O Eastern Surface Seal Installed by X Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material L Depth �n Depth Piller Material i Depth fs TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION DESTRUCTION INo septic system permitted if public sower is V evailible within 200 feet.) InsWletion will sarw: Residence— Commercial Other > Number of living units: _ Number of bedroom) / t•' Character of*oil to a depth of 3 test: /IQ'L Lf'�^ Water table depth SEPTIC TANK ;f Type/Mfg Capacity 249 No. Compartments y *Ke-TREA+MEMt'PH. ❑ �"�•/ f T Method of Disposal X Distance to nearest: Well _s[�L Foundation Property Line _ ..SJ LEACHING LINE No. 8 Length of lines Total length/size 3. .e r FILTER BED ❑ Distance to nearest: Well .�09 Foundation 4,0 _ Property Line 6 L SEEPAGE PITS 11 Depth Sirs Number SUMPS LI Distance to nearest: Wall Foundation Property Lim 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, stats Issas, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "1 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 workmen's compensation laws of California." Contractor'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 lawn of C lifornle.I The applicant __a 7R f r squired inspections, Complete drawing on remover" sidde. Signed X Title: !f11th[-1A7(lr Date: A0 rF/ L DEPARTMENT USE ONLY /(� Application Accepted bye0l V i Date /��y -1967 Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT pUE AMOUNT REMITTED @Ci45 RECEIVED BY DATE PERM17'NO. . F RIi.1.laFY.,,.,, \� ,� wA- � syo 0->3210 <7o -Mi FM:F a1