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APPLICATION FOR PERMIT /¢1SD For, a Vapor ��c frwcfrorf ��Ia'i'�eS!" SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES we If 44 3 -,2 11j- ENVIRONMENTAL HEALTH DIVISION �'�s �ay.sort u1Y1 . , PHONE (209)468-3420 1* 29 SCr�`atil� u P O BOX 2009, STOCKTON, CA 95201 -1re„n !5'� i 4aS•Hsr 9s , RERMIT EXPIRES I YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to San 3oaquia County for a permit to construct and/or install the work herein described. This application ie made in compliance 'i.th San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address —1 /00 Al, wr I54/] U),L f/ City S�'OGt fp-h_ Lot Size/Acreage � lUe5fi / Owners Name _C(rc4 _�tl1a �h'7'�fD- ` Address 5-r fYd nandf �4phone 1S z/olo7l0� ), T^— c4 Contractor Ze- r /i nI4 Address M& /-I License No.CS7tZY517?Phone ^�S TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT DESTRUCTION C1 Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ e�r�7t'� ,'�. THER Qa / Mpnitoring We';/, G a4d 14iper r•C ryyertr�n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE elf CyJ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USf TYPE OF WELL PR0I LEM AREA ~CONSTRUCTION SPECIFICATIONS ir�ndustnal ❑ Open Bottom C Manteca Dia- of Well Excavation x " Dia. of Well Casing C Domesucl Private LWI`iravei Pack r Tracy Type of Casing 5e- edi k, go PYC Specifications i Public Cl Other t ( Delia Depth at Grout Type of Gro u pro* sr I I Irrigation Apptox, Depth I I Eastern Surface Soul Installed by Y4,Z a'> r'r' Gr . Repair Work Done 0 T of Type Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Z Depth � 419 Depth Filler Material 8 Depth ryf} TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION l 1 INo septic system permuted if public sewer is FFk available within 200 feet.) Installation w4i serve: Residence _ {Commercial ____ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 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 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Properly Line I SEEPAGE PITS 11 Depth I Sire Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work wdi be done in accordance with San Joaquin county ordinances, state laws, and Y rules and regulations of the San 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, l shall not employ any parson in such manner as to became 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. 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant list Ialllor all required inspectio . Complete drawing on reverse side. Signed X Title: Date.- 7�' I"D9,P� ►' Date: qikZf FOR DEPARTMENT USE ONLY Application Accepted by Date 0 Area Pit or Grout Inspection by f Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. hatelton Ave., F 0 Box 2009, St o tots, CA 95201 X 9 FEE INFO AMOUNT DUE AMO/jUNNT REMITTED 1CASH RE D BY '] DDACT,E. {�j�PERMIT NO. . EH 13-I4IREV.1in31 9 �V �L / I/r l `v �fN �V~�'.P S-7 E M 11.26 i�