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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEAL H CES ENVIRONMENTAL HEALTH DIVLSI A .�� `/wA,e. 445 N SAN JOAQUIN, PHONE (2094 0 P O BOX 2009, STOCKTON, CA 9 —13 PERMIT EXPIRES 1 YEAR FROM DATE'nFgS�7 (Complete in Triplicate) ,,�, µ �Ld- ` it ( .unr.la....�� Application L hereby made to Sea Joaquin County for n permit to construct rend/or ins to application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joe4uln County Public Health Services. Job Address a 6a 00 a-+IRIIE''A 9.,L City _ Lot Size/Acreage (O Ac�QES Owner's Name �ddressSryyi r- Phone Contractor G-d-� ,o raTt� Address ! `T ' 06" QIy - License No. ?«S"Jai Phone -3 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well ❑ -° PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pscir7 ❑ Tracy Type of Casing_ Specifications - I') Public fl Other f1 Delta Depth of Grout Seal Type of Grout— [ rout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by ,XV• Repair Work Done ❑ Type of Pump H.P. State Work Done _ (� Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION P# REPAIR/ADDITION I I DESTRUCTION I I INo sephc system permitted if public sewer is W available within 200 feet.) Installation will sane: Residence -X, Commercial_ Other Number of living unite I Number of bedrooms Charactef of soli to a depth of 3 fast: CI A e �J k-'A Water table depth SEPTIC TANK K Type/Mfg •¢ JMP� Capacity jr4Df5 No. Compartments PKG. TREATMENT PLT. 0 � Method of Disposal Distance to nearest Well r-sXD-l= Foundation �.b y Property Line LEACHING LINE 54- No. i Length of IIna9 C-,) 40 Total length/size FILTER BED D Distance to nearest: Well -')n Foundation Q0 y Property Line /Sa y SEEPAGE PITS F4- Depth �S Size _ 6rr Number 4 \� SUMPS 11 Distance to nearest: Well ,l_AQ- Foundation Sar Property Life DISPOSAL PONDS ❑ 1_ I hereby certify that I hove 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 following: "I certify that in the performance of the work for which this permit is issued, I shall not N employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of subcontracting signature conif W 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 r I raquil tris cbons. Complete drawing on reveres side. Spred X Title: zpLJfl EFfr— Date: bJ - if 7 -9r3 FOR DEPARTMENT USE ONLY Cr Application Accepted by � Date / � � Area J�t or Grout Inspection by �,zi;Oa Date�� Final Inspection by e Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services f 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE 1" �) INFO AMOUNT DUE AMOUNT EMITTED CASH RE RECEIVED BV GATE PERMIT NO. :H n33E IAEV..1.s� E ? �l/.) H 14 as