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APPLICATION FOR PERIdIT O SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 Sir STrcn/ CUR-rigm+z M41/v P=IT EXPIRES i YEAR PROM 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 San Joaquin County Public Health Services. :506- m&P /91�011(6 RottoS Job Address 'r LN_ �� ^ 4W7p ID City Lot Size/Acreage Owner's Name 4:27Y OF s�� /�/ Address 6 �► G'lw� y ✓�T� Phone Contract 0 N dress t� E, rAylL= License N0^522Z68 Phone 2`1/119_13MIS— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0'Out Of PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERTg(- Meni4spine Wall L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. TEST FOUNDATION AGRICULTURE WELL OTHER WELL /D�fv /Z► INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6If?0/ 14. E] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Spoo4ee"em M Public Cl Other 0 Delta Depth of Grout Seal rewt - Cl Irrigation Approx, Depth ❑ Eastern Surface Soul Installed by Awax— 1317.1 ZW Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth i r ath V =^ . TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAI /ADDl I RU I ( o,se t c s t permitted if public sewer is `� ava(iabe wu 200 feet.) Installation will serve: Residence_ Commercial_ Otfte AXL* VSOW without Number of living units: Number of bedrooms"work being GO�IPI M, of ins jpg Character of soil to a depth of 3 feet: 9 9 ble depth SEPTIC TANK O Type/Mfg y ±---nLiro;brAcityA Hpalth iVWO@mpanments T PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify 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 the San Joaquin County Home owner or licensed agent's signature certifies the following: "I cartify that in the performance of the work for which this permit is issued, I shall nof employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur 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 tt c� uired inspections. Complete drawing on reverse side. Signed X C® •� Title: �—�� 6f�OZOZ'S !ST" Date: �`LL-1 FOR DEPARTMENT USE ONLY Application Accepted by Date �' Z Area 12L:C Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH 13.24(REV.1/85) e- /) I-4N EH 11.26 � t�