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-• APPLICATION FOR PERMIT y SAN JOAQUIN COUNTY PUBLIC EL . TH OYICES �IRNLSDI PHONE (209)468-34201TTd �v TOAAV NIOISIAIQ H.LTM•IV1NaWN0?,I1&§OX 2009 STOCgTON. CA 95201 S801AIRS H.LlVaH 317Md" a '�S 1 yEAR FROM DATE ISSUED - (Complete in Triplicate) AUG •^�0 � 1 ) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. TThis an application is made in compllaace with San Joaquin County Ordinance No. 51+9 and 1862 and the 8161 V,�"VIVi:"IV IX0AC�i1Vi i Joaquin County Public Health services. C' PERMIT/SERA/{CES f l l l N,AU 1< /Q/•l/F — City �CK'Ta- Lot Size/Acreage Job Address V Ji, STR b A T SO Owner's NameAddress CA '7 *GC O Phone W5-B 9/-3G 3G•63 pmEic– CiRttE�Sa1TF 13 ?16 - I Contractor Address �,�AJG,�>s CROOyA , Gig License No. SP9-I.zB Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Moservice nitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing / 11 Domestic/Private O Gravel Pack 13Tracy Type of Casing Specifications I'1 Public 1:1 Other n Delta Depth of Grout Seal Type of Grouts4610A QIa6� I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing material I'. Depth Depth �O F'T Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITION I I DESTRUCTION I I lava septic ttic Thin system feet.)ed it public Bawer is Installation will sere: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity___ No. Compartments PKG. TREATMENT PLT.O Method of Disposal V Distance to nearest: Well Foundation Property Lina LEACHING LINE O No. 6 Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sue Number SUMPS L1 Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS O 1 hereby certify that 1 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 certify that in the performance of titf e it is issued, I shad not employ any person in such manner as to become subject to workman's compensation laws of California. o r o i g c acting signature certifies the following:"I certify that in the performance of the work for which this permit is issued.I shad ploy no to man's compensa- tion laws of California." The applicant must can for all required ins , tions. Co plea drawing on reverse side. a►� Title``--�°' ' �ci +-�?, S �' Date: 'fA A / FOR DEPARTMENT USE ONLY Application Accepted by l/ Date Area / Pit or Grout Inspection by �1 ;t. � U� Paul Inspection by Date f Additional Comments: " � rr + ' Applicant – Return a].I� ogles to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 298 S'r" FEE AMOUNT DUE AMOUNT REMITTED CASH K 8 RECEIVED 2Y DATE PERMIT'NO. INFO Q . EN,4Q.uEv.�.�s�� l�, �a 1 `t' M `„ EN �•m