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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV I RONJ=TAL HEALTH° D I V°I S I ON <br /> P O BOX 2009, ST=70N, CA 95201 i <br /> (209). 468-3447 ! <br /> (Complete inTriplicate) <br /> Application is hereby Dade to Sao Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is s+ade is compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Risgulations of San <br /> Joaquin County Public Health Services. �►c <br /> Job Address City <br /> �� �i�►�7^� VW!f 600. lbN3 Lot Site/Acreage r Z. <br /> Owner's Name Eats ct-A O�S•A• Address d&4 Pho"; <br /> ^; LAL <br /> Contracts Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELLX VW WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of ryice Vell <br /> PUMP INSTALLATION O SYSTE*-AJPMfl O OTHER 0 Monitoring Well Cj <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES / DISPOSAL FLD. PROP. LINE . <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , <br /> INTENDED USE TYPE OF WELL PR081EM AREA CONSTRUCTION SPECIFICATIONS // <br /> n IndustriN O Open Bottom O Manteca Dia. of WellExca "f .,1a Die. of WON C ' Z <br /> U Domestic/Private Growl Pack ❑ Tracy Type of Casing Specifications <br /> M Public Il Other Delta Depth of Grout Seal r `out -+'vim <br /> U lavation - ' Approx. Depth /Q;astern Surlics Seal Installed by FvZf L <br /> Repair Wort Done D Type of Pump M.P. State Wor Do / <br /> WMDoetruStion 0 well ew ow ^ -- Sealing Material i Depth ► t4.5 <br /> 1 Depth 13 T&LIer Material i Depth <br /> TYPEOf SEPTIC WORK: NEW INSTALLATION 10 REPAIR/AODITION M DESTRUCTION G IND septic system permitted it public sewer is <br /> available within ZO fest.) <br /> Installation will servo: Revida►q_ Commercial Other <br /> Number of living urtica: Number of bedrooms <br /> Chw eter M-toil to a depth of 3 f", yyaEM tab depth <br /> SEPTIC TANK O Type/Mfg COpacby— No.-Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> D su nce to nearest: WON Foundation Property Line <br /> LEACHING LINE ❑ No. 3 Length of lines Total length/size <br /> FILTER NO O Distance to newest: WeN Foundation Property Line <br /> SEEPA01 PITS I I Depth sin Number <br /> SUMPS - LI Distance to nearest: WaN Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby cvtiiy that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, ander <br /> rule and#AMmions of the San Joaquin County <br /> Monte owner or licanaed agent's signature cenifies the following: "I certify that in the performance of the work for which this perast is issued.I SW not <br /> empby any porton in such meaner as to become subject to workman's compensation laws of California." Contractor's luring or sub•contrar tli0nature <br /> cwtifrM the following:"I cenify that in the performance of the work for which this permit is issued, I shall employ per"subject to workn in's compensa- <br /> tion Wm of CoWorrda." <br /> The applicant n%m yN for ed inspections. Complete drawing on pverse side. <br /> L. Y :L _r 2 <br /> Signed X - -- 'C-'}" Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> AppNeation Accepted by Date .,.._. <br /> Pit or Grout Inspection by Dna S Final Inspection <br /> AddhionN Commertts: <br /> 2 e6!J! <br /> Applicant - Itoturs all copies to: SAN J'OAQOIN'COUM'PUSLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES � <br /> . 445 N SAN JOAQUIN, P 0 SM 2009, STOCKTON, CA 95201 3J•C1� <br /> AMOUNT DUE AMOUNT REMITTED CK I CA RECEIVED 0Y 0 TE PERMIT N0. <br /> IWOIN.4.39 - <br />