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i1 APPLICATION FOR PERM I T SAN JOAQUIN .,COUNTY PUBLIC HEALTH aRRIVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN -JOAQUIN, 'PHONE ' (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE I SU (Complete in Triplicate) ED 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 m City Sr "C4f0,14 Lot Size/Acreage � � Owners Name A) rJ r C 41�' () Address `�!?.0 60_ 1t),96 S�. Phone 4112 � Contractor __,r %g dh/ !) j? LLl7J6Address U?�Es qI5 S`� License No.G-sZ /7 Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ^ SEWER LINES 21f DISPOSAL FLO. AL4 PROP. LINE # FOUNDATION r AGRICULTURE WELL OTHER WELL_:F�. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 93 ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �- Specifications 11 PublicOther Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth i I Eastern Surface Saul Installed by Repair Work Done U Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter r� Sealing material i Depth 4 !9A-7FN7- Depth ��i Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I INo septic syslem permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial,.4... Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg ..Capacity----- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. lL Length of linea Total length/siz A [— FILTER BED ❑ Distance to nearest. Well Foundation Property Line C SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina C DISPOSAL PONDS ❑ `r 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 lit;ensed 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 per n in ouch msWer as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the fo wing: .1 JC*ftl , hatin t performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Rfornla."The applica at ail frequi ins ions. Complete drawing on r derse side. C Signed ^ Title: i�SGC. <<'Lc!�- E Date: 1 -J3 FOR'DEPARTMENT USE ONLY 5T Application Accepted by Date Z Area 761- Do 1J Pit or Grout inspection by Date Final Inspection by Date 1 Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK I ASH RECEIVED BY DATE PERMIT'NO, EM 13}24111EV.1/R5I wM Sq. f�0 n. X20 M s -2I. EM 1�20 l