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APPLICATION FOR PERMIT 41J?d Ac✓/�'� ��' ��'�9��/se- SAN JOAQUIN COUNTY PUBLICHEALTR 5 405 C'ICBSrCE ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PESMIT EZPIREC T vcAR FROM DAT£ ILtzi3O ikoi�i ll (Complete in Triplicate) Application is hereby made to San Joaquin Count for a permit to construct and/or install the work herein described, This Joaquin County is Pude 1n Co�llance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County 1S1S E,1, .$Vy�cee��S !/'QCtrl�S�4yo/.Q�✓� H WAY _ Job Address Il A1 471-e 1131—/c20_O f�� /7 1/ SCity'c� Lot size/Acreage gll,6 S�Prf�jl y04✓L✓��c� �w J ferry Foral7C/ScOr_.0 N Owner's Name _ • Address � _-� /r/QG'kp7 jf Siiif „� �1/) Phone Contracts Address lT _[`SnX /07 CS7 ,Z09f- TYPE OF WELL/PUMP: 7 License No./k;? 73 Phone - NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIONC/� - 8' SYST�EMRE/PAIR Ll OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ��7-E SEWER LINES �rn1- DISPOSAL FLD.�t PROP. LINEL7 � FOUNDATION AGRICULTURE WELL=-!e--OTHER WELL O — PITS/SUMPS �tINNTEN—DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS {s IntlustrlY ial O Open gollom ❑ Manteca Die. of Well Excavation P ../ Dia. of Well Casing U Domestic/Private (!I GravN Pack O Tracy Type of Casing— 9 r $ NCaflons rou D Public 1'1 Other (pelta Depth of Grout Seal .r� M/r,��.1 pp// PLL'type ol'GroutTT-� ❑ Ir°Uation /-*Approa. Depth ❑ astern Surface Saul Installed Dy QTP r /^e'17, y� J Repair Work Done U Type of Pump H.P. __ �� State Work Done 1_1ZS Qom— Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION M DESTRUCTION CI INo septic system E P permitted it public sower is available within 200 leat.l Installation will serve: Residence Commercial _ Other Number of living units: _ Number bedrooms Character of Boil to a depth of 3 feet: 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 Cl No. 6 Length of lines Total length/sire FILTER BED ❑ Distance to nearest: Well Founds Property Line SEEPAGE PITS 11 Depth Sire mbar SUMPS LI Distance [ serest: Well Foundation oPerry Line DISPOSAL PONDS ❑ I hereby comity that I 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 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 subcontracting signature certifies the followin "I unify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. tion Is sliforn■.' Enom:pl The opWicant m at or ell on r��sssr side •7 9'1 - Signed Signed Xw l� / : _ ///ava��acSiL�N Dale: ( - / — 7 OR DEPARTMENT USE ONLY 't p Application Accepted by Data \ ` 1 Area 1 �5 ,SCS Ph o Grout ropeetion by Date O Final Inspection by bete Additional Comments: a o T 1 Applicant - Aetur cops$ o:�� JOAQUIN CO T P BLIC HEATH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOK 2009, STOCKTON, CA 95203' IEEE AMOUNT DUE AMOOUUNTy,REK41T�T�ED CK CASH RECEIVED BY DATES GPERMIT NO. c . EN 13 24 IBEV,tin ai I J :�� ' r.�`.+�--`iJ��_ I I E I � { EN '.P a/ 1 -1111111 s7 I a