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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE 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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sam Joaquin County Public Health Services. KJob Address --1 :3 o 17774_, )(Owner's Name () p "F-7 2,27 5 Address /535S- 41-''‘.;z4.-y —A 12eiphor7e,4c/ (e,.?s 222-e; City 77~ Lot Size/Acreeze 70 4/-ze_r kConti act or - UjA-feAa-- Address TYPE OF WELL/PUMP. NEW WELL 0 PUMP INSTALLATION -0 DISTANCE TO NEAREST; SEPTIC TANK FOUNDATION INTENDED USE 0 Industrial El Domestic/Private 11 Public. — i Irrigation. Repair Work Done .Welf,Destruction License No./L-114-- Phone WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well SYSTEM REPAIR 0 OTHER 0 Monitoring Well 0 SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS J T'YPE OF WELL PROBLEM A E• CONST CTION SPECIFICATIONS 0 Open Bottom o Manteca Well Excavation Oia. of Well Casing 0 Grave Pack 0 Tracy of Casing Specifications Cl Other Delta e lit of Grout Seal - Type of Grout Approx. Depth I I Eastern Surfa Seal Installed by 0 Type of Pump H.P State Work Done Wel Diameter sling Material th 0 Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATIO 4N\..Q. SUMPS FILTER BED 0 Distance SEEPAGE PITS PKG. TREATMENT 'pLT."E1-0 TYPa/Mtg T) 'It/ L-- LEACHING LINE SEPTIC TANK 4--GT4k-,‘""\, ISPOSAL PONDS I I Depth Characterof soli to a depth of 3 feet' /5 --- /''- Number of living unite _L Number of beAr, oorns .1 1 to Installation will serve: Residence ''''1-- Commercial _ Other _ 0 r LI Distance to nearest: Well ce newest: Well ell A}.' 0 No. a Length of lines :tal length/size Distance to nearest: 'Capaity / 2- OO 140f4u4PWW4- Size -...?' REPAIR /ADDITION . FF0:06adat.tioionn ii.::5 prooeft:o. Compartments autne Foundititin a' 6 ir 3 ---76 ' Toth/size DESTRUCTION I I (No septic system permitted if public sewer is ,- - • -711 Pt' r-- 1., / Number _ available within 200 feat.) Property Lino Method of D' 561 4e4C Water table depth No. Lill* 5 O i . 0 - ac fe) -2.--- GI J -4-- 1.13 employ any person in such manner as to become subject to:workrnani Compensation laws-of California." Cofttractor's hiring or sub-contracting signature. certifies the following: "I certify that in the performance of the work for ikriich this permit is issued, I shall •MPloy persons subject to workman's compensa- tion laws of, li • • la " ... , .., 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 shell not I hereby certify that i have prepared this application and that the work will be done .ir( accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County . - . .• - .. . The applicac Mu &required ins tids. Complete drawing on verse s --.. i.., t -RIM& pthelitZ/M-( Tithrr z.....-J--. • .t...,..,...._ E PA RTMENT USE ONLY Application Accepted by CA.A.A. c ....%..140,...cov,..n ,pate • .,) „. tilrri A , Pit or Grout Inspection by Date Final Inspection by NAllt .t" ... ' Additional Comments: 3- 70 - /ea.-4 4,4 ,c 40e..0-e_ VP Applicant - Return all copies to: i ,t-r/I'a 4si. • ....5R a dc6d riAlr -ra APP.- 4 San Joaquin County Public Health Services Environmental Health Permit/Services k -ee.44.0 44$ N San Joaquin, P 0-Box 2009, Stkn, CA 95201 1° Date. Ateb I Co Date . EH 13-14 iltEld. Intiu Eli 14-a5 FEE INFO AMOUNT DUE AMOUNT REMITTED OU Ck I -- EIVED BY _ AATE iflifeW V PERMIT .NO %11 211 g 1