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• APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC REALMICES_Q2 Z <br /> 3 <br /> E"IRON,YSNTAL HEALTH DI ISI&W <br /> 445 N SAN JOAQUIN, PHONE {20 � 42Q <br /> P 0 BOX 2009, STOCKTON, 99241 <br /> R �.� <br /> (Complete in Tripl"CI-- <br /> INV # �v <br /> Application in hereby made to San Joaquin County for a permit to cowtruct iV ren est------ ThistiyplicatIon is made in compliance vlth San Joaquin County Ordinance No 5L9 and <br /> 1662 and the <br /> Rules and <br /> Aegv]ations of San <br /> Joaquin Count;r Public Health Services. <br /> Job Address Za 0 S W Be,��1 a wr i H 4p r by Iye - City 5+0Q kE10% Lot Size/Acreage <br /> Owner s Name f r& Address CY/O�/N//�� ' ' r��'� ���A►hona O V.7— <br /> t✓S 3 3 c �`PY``„'� / �y-��r 7—If Z9 <br /> Cwtractor License Phone <br /> TYPE OF WELL/PUMP NEW WELL D WELL REPLACEMENT M DESTRUCTION ❑ Out of�Servlce Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ lionitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK _7100 "_ SEWER LINES 7 a DISPOSAL FLDPROP LINE <br /> FOUNDATION ,7-1QE>f AGRICULTURE WELL,: OTHER WELL T�O� PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f/ <br /> 0 Industna) ❑ Open Donom ❑ Manteca Dia of Well Excavation Dim of Well Casing <br /> n Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing P-VC- Specrficatwna <br /> I'1 Ptibbe g Other n Delta Depth of Grout Seal ;Q2,l Type of Grout <br /> I I irrigation 3�L Approx Depth I I Eastern Surfacs Seal Installed by gar 11 <br /> Repan Worst Done U Type of Pump H P Stats Work Do.41 <br /> We* Destruction ❑ Well Demeter 2 ° Sealing Material i Depth lVe47L�tn►�Jff/f�•y,fzji7l �2[l� <br /> t{ewr�orii. <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted it pubbc sewn is <br /> available within 200 lest I <br /> Insts"tK rt wdl sa''►'s Residence_ Comrrwrcrol_____ Other <br /> Number of bwV units Number of bedroom <br /> Character of cad to o depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No Compartments <br /> PKG. TREATMENT PLT ❑ <br /> Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE. C1 No & Length of kwz Total length/sue <br /> FIL ounoat,on Property Line <br /> SEEPAGE PITS I I Depth Slre NO Itmi <br /> SUMPS Ll D Wail Foundation Property Una <br /> NDS ❑ <br /> I hereby cernty that I h we prepared this appl,canon and that the work will be done in accordanca with San Joaquin county ordinances, state laws. and <br /> rules and raptrisaorw of the San JoaWin County <br /> Horns owner Or licsnaed epent's signature Owurirs the loltow+ng ' I c ortrty that in the performance of the wart for which this permit is issued, I shall not <br /> employ any person in such rrtarwwr as to bac=m subjeoa to workman a compensation Paws of California Contractoes hrnn9 or sub-contracting tiignature <br /> candies the foWowwV "t camfy that in the podomiimcs of the work for which this permit is issued, I shall employ persons subject to workman a cornlpsnsa <br /> iron laws of California" <br /> The int for all inspecnons Complete drawing on reverse side <br /> SW,d Tide G/irf� f� Data <br /> FOR DEPARTMENT USE ONLY <br /> Applrcabon Accepted by Date 131„ Area • [ <br /> Pk at Grout InspKtion by Date Final Inspection by Date <br /> Commenta r <br /> applicant - Return all copies to San Joaquin County 4blic Health Services <br /> Environmental Health Permit/Services RECEIVED <br /> HA1r <br /> 445 H San Joaquin, P 0 Box 1009, 9tXn, CA 95201 r`El r 1j <br /> FEE — CxAMOUNT DUE AMOUNT REMITTED a RECEIVED BY DATE l• PERNuT No � � � <br /> INFO CASH <br /> M24IAVV „sal fib 39 <br /> H 14Y r <br />