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-, APPI.I CATI ON FOR PERH I T . SAN UAQUIN COUNTY PUBLIC HEALTH V I CES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 R RM (Complete in Triplicate) Application Is hereby teade,to Sam Joaquin County for a permit to construct and/or install the vork herein described. This applicationi'ie mde in eowliance with San Joaquin County.Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public health Services. Job Address `Z 6 4/85 Thor. 40 Z12d City Th d i'"A0*1 Lot 51 se/Acreage Owner's Name. Sa✓h 4v a D t o6 ke- Address T315 .A✓r Phone .207-v-1 Contractor Sni1S era i Atleress �� oX' License No. S¢ZL9G Phone yoT-7�lS-1924' TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ If PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER JRL Monitoring Well ❑ DISTANCE TO,NEAREST: SEPTIC TANK 14 A SEWER LINES NA DISPOSAL FLD. NA PROP. LINE SIA_ :I FOUNDATION ttA. AGRICULTURE WELL , Nh OTHER WELL 94AtPITS/SUMPS dk- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation_?•5 r+ewrL Dia. of Well Casing tl.Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing PVC. __. Specifications I'1 Public Other n Delta Depth of Grout Seal Type of Grote 40" _leaf C a�•++ T +N�'V ,� I 1 Irrigation IS Approx. Depth I I Eastern Surface Seat Installed by S E S Repair Work Done L] Type of Pump N.P. State Work Done _ Well Destruction ❑ Welf Diameter Sealing N.teriwl i Drptl+ f� Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is talft" y available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character o1 loll to a depth of 3 fen: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity Na. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 6 Length of lines Total lengthtsiza FILTER BED ❑ Distance to nearest: Well Foundation Property Line does no f A I SEEPAGE PITS It Depth Sire Number SUMPS Ll Distance to newest: Well Foundation Property Line DISPOSAL PONDS ❑ (00,-t Ha} 'CLIP P 1 1 hereby coMity 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 tM Sen 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 shag not employ any person in such manner as to become subject to workman's compensation laws of California." Contractofs hiring or sub-contracting signature certifies the fosowi V:"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 laves of California." Tfwappy nt 'st for it tions Complete drawing on reverse side. Sip l� u twYfe✓ Title: 0.4kefll 1lJ4�.� Date. Z7 /ffS W 4F FOR DEPARTMENT USE ONLY Appy t' Accepted by Date Area Pit or Grout irtapection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N Sae Joaquin, P O Bar 2009, Stkn, CA 95201 FEE AMOVNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO, INFO CASH . E0413.NInEv.rresi tM 1��