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APPLICATION FOR PERMIT, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009,' STOCKTQN, CA 95201 r (209) 468-3447 PEMIT EXPIRES 1 YEAR FROM RATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is merle in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San j Joaquin County Public health Services. e . Job Address 4/, -J4-6LCity ",r;e -fib Lot Size/ creage � f Owner's Name Address _ Sdf=fr _ - Phone Contractor_i�„G�J �E, lt/�6� Address 7 N, License No. 4� 'S-3j76_F'hone f 1"39�7J ^TYPE OF WELL/PUMP: NEW WELL ❑ WELL'REPLACEMENT Cl DESTRUCTION O out of Service Well 0 _ PUMP INSTALLATION ❑ ��- SYSTEM REPAIR Ll T -- OTHER'-o—,Mori-tor-ing-Well—C�. DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES ' DISPOSAL FLD, PROP. LINE # - -�• - —• --^-'FOUNDATION-.. `'AGRICULTURE WELL OTHER WELL' PITS/SUMPS INTENDED USE TYPE OF WELL P0615C`EM AREA CONSTRUCTION SPECIFICATIONS, fl Industrial O Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing i �. I U Domestic/Private 0 Gravel Pack -� L] Tracy F -Type of Casing Specifications „ Q Public Cl Other ❑.Delta r Depth of Grout Seal Type of Grout MI Irrigation —.Approx. Depth ❑Eastern ca Surface Saul installed by Repair Work Done U Type of Pump H.P. State Work Done 1 & ) Well Destruction © Well Diameter _Sealing Material Depth fit,� , �1. Depth Piller Material i1 Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION 'REPAIRI.A'DDITiON M ..DESTRUCTION G INo septic system permitted if public sewer is _ ; c 3. available within 200 feet.) , Iristatllation_will serve: Residence . r Commercla!T 'Q1her } 4 y Number of living units: Number of bedrooms`_L_1 ` Character of soil to a de_pth�f 3 feet: ' Water table depth r SEPTIC TANK. `4[3, Typ/Mfq; —_ ` �- --capacity J (.a Q _ No. Compartments PKG. TREATMENT PLT. 11 Method�ofDisposal.- Distance to nearest: Well 14749 __ Foundation T Property Lina f LEACHING LINE No. & Length of lines _3 - 4-12 r — Total length/size FILTER BED n Distance to nearest: Well _/QD_ Foundation _ Property Line /d0 i f SEEPAGE PITS I Depth 2S'�, - Sire r� Number E SUMPS LI Distance to nearest: Well 570 ` Foundation Property Line I DISPOSAL PONOS ❑ [ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws, and k ---•.--ruies,and-regulations of-the S a n Joaquin--Coun ty 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: "I certify that in the performance of the work for which this permit is issued, l 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. LL. Signed X _ --- Title: Date: FOR DEPARTMENT USE ONLY CalAccepted by Date Area Z / (PJ l Grout Inspection by Date glFinal Inspection by Additional Comments: - Applicant - Return all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES :Ili • ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 r -'i FEE AMOUNT DUE AMOUNT REMITYED I CK RECEIVED BY DATE PERMIT'NO. INFO (� �-C7ASH ^ . EH,3.24IREV,iix51 �G 1 !J� l�l —ql I.-�q E f 1{.26