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I�I Is 4, ;'APPLICATION FOR PERMIT ;j I? SAN JOAQUIN. COUNTY PUBLIC HEALTH SERVICES I 'ENVIRONMENTAL HEALTH DIVISION .�� MM l� 1601 E. :HAZELTON AVE. , PHONE (209)46$-3420 >• ` P O BOX :2009, STOCKTON, CA 95201 :P i' D C GCl3 PERMITEX PIRES 1-YEAR FROM DATE ISSUED i . (Ctamplete in Triplicate) Application is here made to San Joaquin Count fors work i �$c'csr'1W This PP by q y= permit to construct and/or install the tori here n s application is made in compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Il Job Address :Z 36a eyt,,r City .TYZF}_cly Lot Size/Acreage j # STfkt�lA TPuST ya �, Rtvt�2 �I aL��n1o7T�r3aN C .1u.ta-E7 700 I Owner's Name �a 5_ 1+ tq FL-L- Address SM 11" C�-t&6 -SL SA,0 TO 285 Aho`e 402 -C7 '3-9- ►2(5?5aA,, �,�� Contractor �� LT Addre55_4 1 fa 74 Qk1STy Sr ��ense No.�.5�:P one � — TYPE OF WELL/PUMP: NEW WELL 'O` WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIO ❑•'. SYSTEM REPAIR ❑ OTHER ❑ Monitoring well i fI .i DISTANCE TO NEAREST: SEPTIC TANK IV "',SEWER LINES !::z DISPOSAL FLO. All°►WETHER PROP;LINE Is` FOUNDATION N A --' -AGRICULTURE WELL N1Ar 0 LLnlP. PIT P 9Lr S/SUM S INTENDED USE TYPE OF WELL PROBL-Efk AREA CONSTRUCTION SPECIFICATIONS I J /1 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation V. Dia. of Well Casing rf �IDomestic/Private ❑ Gravel Pack Trac T rr _ � y E, Type of Casing Specifications- e�d I'1 Public (Other >"11IaR4 L&A Delia Depth of Grout Seat � Type of Grout_��f4�; Et�frf I i lnigation 2o:E Approx. Depth I Eastern Surface Seal Installed by _DOUC45� Repair Work Done V Type of Pump r b .1 ,H.P. State Work Done Well Destruction ❑ Well Diameter ,, Sealing Material & Depth N Depth oZS :I " E Filler Material i Depth 492- hCONTE2 Stt�LFt 17 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 ::REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted it public sewer is available within 200 feet.! Installation will serve: Residence_ Commercial'—' ` Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet-. 'i E! Water table depth " SEPTIC TANK 0 Type/Mfg Capacity No, Compartments i PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: ''Welt Foundation Property Line 11 LEACHING LINE Cl No. 8 Length of lines "� `Ir Total length/site FILTER BED ❑ Distance to nearest: Welly Foundation Property Line i. h" li • SEEPAGE PITS 11 Depth Sire'i Number SUMPS L1 Distance to nearest: well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ojdinances, state laws, and rules and regulations of the San Joaquin County it 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 mu call for ail requir nspections. Com trawing on reverse side. i Signed X t Title: GSNf4 r CA, -P-G s°'33 Date: IIAZ Z21 ;FOR.DEPARTMENT USE ONLY Application Accepted by Date G C Ar,ea v Pit or Grout Ins pection by Date Final Inspection b Date Additional Comments: Applicant _ Return all copies to: San Joaquin County Public Health Services, ,Environmental Health Permit/Services 1601 E. Rnselton Ave., P 0 Box 2009, Stockton, CA 95201FEE i t INFO AMOUNT DUE AMOUNT REMITTED ASH CK RECEIVED BY DATE PERMIT NO. ENt371irrEV.r�nsr 07 �_ .26