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APPLICATION FOR PERMIT SAN -1AQUIN COUNTY PUBLIC HEALTH 'RRVICES \,,,ENVIRONMENTAL HEALTH DIVISZ,vd 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is wade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. -��,^ Job Address O v,J/FMsr EI.DEB 0_rhftB r fl City S_.L'-f��-- Lot Size/Acreage l� OwneisName '��../"�s�a-+r1y,Vt ��■�Jf1J^r`��+^°ass � 1T.�.�IOfO�(�B��/��11 r"+�EJ�af�f Fhone Contractor�>�asf rf 16111."IT�ABtlrlfis' 1110 -9& �. 19FAU N Phome TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ER)( Mon toring Well^U DISTANCE TO NEAREST: SEPTIC TANK 11 T SEWER LINES _�f DISPOSAL FLD. PROP. 1 Io4�D FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS -�/� A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack Tracy Type of Casing "" Specifications I'1 Public 04ther fl Delta Depth of Grout Seal Type of Grout I I Irrigatlon 10Approx. Depth I I Eastern Surface Seal Installed by --- Repair Work Done L3 Type of Pump H.P. Stets Work Done Well Destruction ❑ WON Diameter Sealing Material i Depth Depth Filler Wterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Instaltation will sero: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of sole to a depth of 3 fast: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. 11 Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application arld 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 candies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person M such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant SN for AN requlrpsctions. om a drawing on reverse side. s' n.e x l//V/J < </4 Z G s#` a2 3 • r0 -- Title: Date: V 3 FOR DEPARTMENT USE ONLY •� ST Application Accepted by � Date ' 73- Ares 2.9-0 t� Ph or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services • Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE FO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. fN 1324(REV.rear Sg fN 14.1 g�. i11 vv1 5 2� 93 93.og59 m