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k APPLICATION FOR PERMIT i i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION � P 0 BOX 2009, STOCKTON, CA 95201 t (209) 468-3447 PERMIT U21999 1 YBAR 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 Ban Joaquin County Public Health Services. // J Job Address f,;�Z O ^ N_'XiFf City Lot Size/Acreage .2 np //-�•• �y Owner's Name U� '�t r�� C.2 CV Address '-32 Phone Z- 23 /Door'--'yb •� '151-1 Contractor SLF_iX B/2 + S i wr�t Address _ 52.3 P-Ni'lf YEA, _ _ ___ License No. `_cl 6 7o Phone 5_32 37 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT D_ DESTRUCTION 0 Out of Service Well L1 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /0 6� DISPOSAL FLD, PROP. LINE �SO FOUNDATION _ ... AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑.Open Bottom -0 Manteca Dia. of Well Excavation7 --Dia. of Well Casing a , U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casingy� Specifications 0 Public I<TOther IODelta Depth bf Grout Seal s 94ek rn40 Type of Grout U irrigation Z�E Approx. Depth d Eastern' Surface Seal Installed by �4�2 Repair Work Done 0 Type of Pump S ifQ ��" H,P. State Work Done _ Well Destruction 0 Well Diameter � Sealing Material i Depth _ 41 ZZI Depth 3 S' Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION G (No septic system permitted if public sewer is available within 200:feet.) Installation will serve: Residence— Commercial— Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth j SEPTIC TANK. 0' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0{ "•Y = Method of Disposal Distance to.nearest:• ,,Well Foundation Property Line LEACHING LINE L'1 No. & Length of lines Total length/size .3 FILTER BED n` Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county-ordinances, stale taws, 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 applicant t tail for all required inspections. Complete drawing on r v rse si rr 11 a Signed _ J 74L i, Title: v Dater �4 F PARTMENT USE ONLY Application Accepted by Date�,L r Pit or Grout Inspection by Date �"ZS" Final Inspection b Date Additional Comments: Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 H SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH t7-24 lNtiV.��qs, g� Q0 232 EH ;b2e