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7• / /0 / APPLICATION FOR PERMIT [%pu l7 SAN JOAQUIN COUNTY PUBLIC HEALTH ERlg AS. .j ,2 17 ENVIRONMENTAL HEALTH DIVISI I� li ��l 445 N SAN JOAQUIN, PHONE (209)4 g"� I e— P 0 BOX 2009, STOCKTON, CA 9 ;VAC PERMIT EXPIRES 1 YEAR FROM DATE II SUED (Complete in Triplicate) 111V ff . � 1Q`'1 Application is hereby made to San Joaquin County for a permit to construct end/or install the vor ere application Is made in ccopliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address V0 6,5�r/!1/ C,ty1>J //1[dLF�C�R- Lot Size/Acreage Owner's Name- (n'• �lG`�`/�� rA�dddress/�� lf'n dL 5"1" Phone A Contractor �/ %Ci�-�r5�._Address f"Gd' 2 4ita TZ4P4 1P License No. � � Phone TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ _ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well L-j 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 D Industrial O Open Bottom ❑ Manteca -Dia. of Well Excavation Dia. of Well Casing ��p 7 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of-Casing Specifications I'I Public Cl Other F1 Delta Depth of Grout Seal Type of Grout - I I Irrigation _Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Tiller Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION>< DESTRUCTION I I (No septic system permitted it public sewer is available within 200 loot.) Installation will serve: Residence.L Commercial_ Other- Number of living units: _� Number of bedrooms -3 .. Character of wil to a depth of 3 feet: - ., y L 4m,rO Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Welt Foundation Property Lire LEACHING LINE No. 8 Length or lines 'CJ " Total length/sire Sin FILTER BED ❑ Distance to nearest: Well 33/'� Foundation :520,0c- Property Line i SEEPAGE PITS [ I Depth Sire- Number SUMPS LI Distance to rexosc Well Foundation Property Lina 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, stale 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to worknun's compensa- tion lava of Califomle." The applicant must cam for allreq fired inspections. Complete drawing on re,Cvar �q ,g Y*�-�_ C� . �K�,u - Date: 1F—Ze!, Signed X � Title: >. s��-�N F�EPAR EN � 7 ,, Application Accepted by �'-� Date - - r a u 'it or Grout Inepactlon by Date Final Inspection by Date y kional Comments: ,plicant - Return all copies to: San Joaquin County Public Health Services Environmental Health ,Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DOE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO -. 'C �/ iP0 �� r �i'9 / • CSC d �� LJ � //�