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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 91Vfit' 1,142- 'AJ AA A/e City :5 Ire x 7VAc1 Lot si ze/Acreage 1.5-ax A 34'4- 4 Owner's Name �/» ' •rReAI E S11EP,1,W eD Address 1A/"E Phone 146& - Contractor F'LayD Address 7,4LI 42>.SLBceT A✓c'. License No. Phone LC 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 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 ❑ Industri(al O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 17 Other n Delta Depth of Grout Seal Type of Grout 1 I Irci0aiton _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Wall Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 01 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public &ewer is available within 200 feet.) Installation will serve: Residence _i� Commercial_ Other Number of {wing units: —L Number of bedrooms Character of soil to a depth of 3 feet: SAV PjV 0, -Ay { 9A w1 Water table depth SEPTIC TANK O Type/Mfg P�-L Capacity 1lvo47 No. Compartments �- PKG. TREATMENT PLT. ❑ Method of Disposal / ^/Distance to nearest: Well 1> Foundation S Property Line 1`. LEACHING LINE LT No. 8 Length of lines -2-(_99 Total length/size a' FILTER BED ❑ Distance to nearest: Well /nc �- Foundation /O ' Property Line JF/ SEEPAGE PITS I Depth IF Size 4X if.)(8 Number 3 SUMPS LI Distance to nearest: Well IOD I Foundation 2 d Property Line S' 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 oanifiee One renewing: "I aanuy that In the performance of the work for which this permit is issued, I shall not emPley any person In such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatuis 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 California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: L�117L7tt, Date: 12-3-g-'72 „ SE ONLY —��^� Z_ 02 Zie tionAccepted by Date 11- - z Area CT1.I 1 r Inspection by T eA!�-/.r./LG ere.�f Date /` z Final Inspection by �" Date Z Additional Comments: // Applicant - Return all opies to: an Joaquin County Public Health Services Environmental Health Permit/Services 1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEECK If INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. :04Lazahair.Orxa IIL1 , O0 11 q. 00 rrOf t4.a/ I-!7- Z, [F.2-3-7/7