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C) APPLICATION FOR PERIL I T (—) SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E"IRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sun 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. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _/_5,co_, EA 5—r U/y r_7 57-k e l-- - — City Lot Size/Acreage 11 .4 c- Owner'a Name f.Ell'i l}�CAddress 12 Q LV ; LC)bI 14!26 11-��j�� Phone Y?—' '�-733 r— s, Q Ui[e 1NG. Lcs dAn+Ct > e A 95Yo 35" Cantracttlr l L/ Address -S r• s�''� t _ License No. 7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 WELL12 OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial )A open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private 0Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Ptibfic F1 Others'- A l_n Delta Depth of Grout Seal Type of Grou Irrigation I I A �~r Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction 1p, Well Diameter sealing Material i Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION ( I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial T Other Number of living units: Number of bedrooms Character of sod to a depth of 3 last: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 cenifies 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: "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 applicMi ll for all required inspections. Complete drawing on reverse side. G� Signed K �G' -f`4 •,t_ Title: A9pl"T Date: FOR DEPARTMENT USE ONLY �.�d I Application Accepted by _ Date r Araa �to Pit or Grout Inspection by Date j� Final Inspection by Date rt Additional Comments: ' 't�� L r^�lr' ' 2 _ Applicant - Return all copies :p: San Joaquin Countitq Public Health Services Environmental Health Permit/Services 445 H San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PrERMIT'NO. . EM 13-74 IREV.e/M Sl [1;+� 0A EK 14.76