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qb fir' i'. I -C�o (r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��-!`r� Z Z� ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (1 0 (209) 468-3447 13- ILI C/10T(3 -1"A PERMIT EXPIREa 1 YEAR PRQX ,DATE ISUyED SCkuL—,-Xr (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 n Joa n County rdinance No. 549 and 1862 and the Rules aztd Regulations of San Joaquin County Public Health Services.�� Job Address rL 0 V S L_0Ctqr10AS city-TILA C'-!:l Lot Size/Acreage Owner's Name V/L`(L 61� S U w 4(t!S._ Address LV �.o Phone Coniracior C.l�� (� GG" AddressLicense No. r Phon bir' GS-J"0tJy TYPE Of WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Ci DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION O SYSTfM RfPAIR_C7 OTHVggF 17 014 it1 ra-/el�$ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P. LINNNNLE t✓ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — 13— /Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �" !y C] Industrial 0 Open Bottom ❑ Manteca Dis, of Well Excavation Dia. of Well Casing 1 U Domestic/Private C1 Gravel Pack 0 Tracy Type of Casing Specifications M Public Cl Other U Delta Depth of Grout Seal Type of Grout Pew G trnpation .Approx. Depth © Eastern Surface Seal Installed by Gl�^� ^ {� Repair Work Done U Type of Pump H.P. State Work Done _ - Wall Destruction 0 Well Diameter Sealing Material i Depth n Depth Filler Material & Depth . f TYPE OF SEPTIC WORK; NEW INSTALLATION Ll REPAIRIADOITION 0 DESTRUCTION C1 (No septic system permitted if public ialp available within 200 feet.) Installation will serve: Residence_ Commercial— Other /q L(r- rte? t a K-11 t.. L. �� !�!? Number of living unite / -t J`-Number of bedrooms � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 13 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Ll Method of Disposal Distance 10 nearest: Well _- - Foundation Property Line 1 LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line` DISPOSAL PONDS 0 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, &no, 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, 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 must ca quired inspections. Complete drawing on reverse side, �p I Signed Title: I�N• G� , � E' Date: FOIi DEP R ENT USE ONLY Application Acce tsadJb� ��—Q22f7 / Pp p Y Dateez Area A Pit or Grout Inspection by Date Final Inspection by Q Date ^24 _,Addhionai Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2000, STOCKTON, CA 95201 FEE INFO OUNT DUE AMOUNT REMiTTEO CASH RECEIVED ay DATE PERMIT'N0. . EH 13.24 rfu:V.I/A 51 q J~ EH 4.2a r E a r� q' .ql 11_0gVj {