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'low- APPLICATION FOR PERMIT Iwopv PA YiW EN SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES REC,Vclj ENVIRONMENTAL HEALTH DIVISION •-. 1601 E. HAZELTON AVE. , PHONE (209)468-3420 JUN 17 P 0 BOX 2009, STOCKTON, CA 95201 P ��N 10AQUIN COi1NTY LIC HEALTH SERI/ICES P MIT EXPI(CompRES I YEARin FROM RO DATEicate) ISSUED FNVIRv^N,ti1ENTAL HEAL L. Application is hereby made to San Joaquin County for a permit to construct and/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. Job Address 6J� S. MacA.,r4A'`r City -rcc,q Lot Size/Acreage Q -2-1 Owner's Name L,- �'+� 1�c_c:fri c Trc.ns Cc,. Address Linc h(puke 1 1�1aZa� Sc n I=ran c�Sc� Phone 4%s 541-2 7 3 fs. 14yt4je. Si,. ContracIorEx 2 1aro.Vot% 2nc.• Address S4°cIt-1on r CA gs2o5 License No. 51Phone Z°`t)46S'- S;itZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 'Zo r FOUNDATION AGRICULTURE WELL OTHER WELL* ZCoo I PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom C3 Manteca Dia. of Well Excavation It Dia. of Well Casing 2 11 1.1 Domestic/Private ❑ Gravel Pack X Tracy Type of Casing GeA%- 40 P'4 L Specifications (1 Public .Other fl Delta Depth of Grout Seal -1-0 A&/J-Type of Grout CEMENT I I Irrigation ZO'Approx. Depth I I Eastern Surface Seal Installed by Spealtk.n \e�1c.�� Ing eelo Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Z.r Sealing Material 3 Depth "q 15A4g:. (Q Depth Filler Material i Depth '�e r SUS TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 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 sub-contracting signature certifies the following:"1 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 3�+a�� S+ce Title: M4 1_ Date: FOR OEPIRTMENT USE ONLY Application Accepted by ^- Date Z2 (n^ Area Pit or Grout Inspection by Date Final Inspection by Date S U J v Additional Comments: \ Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. -INFO CASH cro . EH 13.24 111EV.tin sr � � -7(241 I� EH;1.3e 'VAO Cr -