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APPLICATION FOR PERMIT 310- z-7 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION PAYMENT P O BOX 2009, STOCKTON, C RECEIVED (209) 468-3447 S E P 2 5 39.90 PERMITY SAN JOAQI 1`4 r (Complete in Triplicate) kt ao s - Vrii/E S7' PUBLIC HEAI:I { C . Application is hereby made to Sam Joaquin county foroa pe mitordtoaconstruct9and/andor install the Rules and Regulations °t' application,ie made in compliance 11 Joaquin County Public Health Services. k 57 1 Lot Size/Acreage �- Job Address �.} V�J . . i •�., �SlSur. c>GwR -D�'L.arDr g52,4633/-Z7-76L-OV I Phone Owner's Name � p.]l/ , ST�G 'scense No. Phone 4.657$7 • Contractor SWG7`T�vM � TB1dre55 2 WELL REPLACEMENT 0 DESTRUCTION ❑ Out Of Service Ne11 C1 TYPE OF WELL/PUMP: NEW WELL ❑ Monito?rimg Well C7 SYSTEM REPAIR,❑ OTHERQ �� a t. r =— ._ PUMP INSTALLATION ❑ " _ O UNE DISTANCE TO NEARES7:TSEPTIC T k-NK"jl(3O''1-7�SEWER.LINES_.�'L�'• —.Dk5P05AL'_fLD, r 7LfJ�r PITS/SUMPS FOUNDATION �_ AGRICULTURE WELL �� OTHER WELL --�-�- _ - INTENDED USE #' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl industriat ❑ Open Bottom ❑ Manteca Dia. of Well Excavation crit-r+£ Dia, of Well Casing Pack ❑ Tracy Type of Casing Specifications U Domestic/Private Ll Gravel a GeN t'r*1 t10t15 Type of Grout R Public � I 1 Other ❑ Delta Depth of Graut Seal 43;EN � CJ Irrigation } Appro'x. Depth ❑ Eastern Surface Seal Installed by H.P. State Work Done Repair Work Done U ! Type of Pump Sealing Material i Depth - Well Destruction O Well Diameter f _ Filler Material f: Depth Depth ZS F TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIRIADDITION 0DESTRUCTION D evlailablerwthin 200 lestnstem jea if pirtilic sewer is w iInstallation will-serve: 'Residence.— Commercial _... Other Number of livin units:: Number of bedrooms g ? Water table depth Character of boll to a depth of 3 feet: r7� SEPTIC TANK `, ❑ Type/Mf Capacity No. Compartments 1 t PKG. TREATMENT PLT.❑ :ecu . r 'i Method of Disposal ' ' Distance to'neeresv, , : Well- ~ .,.Foundation = Property Line LEACHING LIN • ❑ No. & Length of lines Total length/size T r FILTER BED r f! Distance to nearest: Well Foundation �`1 f LTA- _ Property line 71.LIn SEEPAGE PITS l I Depth Sire Nymber 1 • 'SLfMPS-�r �:.�'-"L`l"Distan 8 fa rieares[:i -1Ne11 - Fourtdatloh ,� Property Erna j 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, end rules and regulations of the San Joaquin County s -4- 6. Home owner or licensed agent's signature Certifies the foliowing: "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 fhe`work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." ? The applicant tali for a jequirsdspe, i s. Complete drawing on reverse side. ^ nT Signed €• Title: ?'SAF Al t�£EQ.» _ Date: + F R DEP TMENT USE ONLY — _-- a Application Accepted by Date 0_ Area Date Pit or Grout,Inspection by Date Final inspection ti l Additional domrnents: Applicant Return ell copies o: AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES r "'°'k?1S"`N'`CSAN""JOAWUIN, P O BOX 2099, STOCKTON, CA 95201 FEE.- EE- 1AMOUNT DUE ,.; AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO.' O i T EM13-24(REV.=/M6) O �� •2 r; err:�•ta _.