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rte! APPLICATION FOR PERMIT SAN"%rOAQUIN COUNTY PUBLIC HEALTH`-I1SRVICES ENVIRONMENTAL HEALTH DIVISION �V �a 445 N SAN JOAQUIN, PHONE (209)468-3420 hC SpYl/ }J�F Pae P O BOR 2009, STOCKTON, CA 95201 �It _ T IRES 1 YEAR FROM DATE ISSUED 111,�'`/ � (Complete in Triplicate) Application In hereby mode to Ban Joaquin County for a permit to construct and/or ins tall the work herein described. This application to made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address / I r-:/ '/" CiIV/ y•- t r..., If' Lot Bl to/Acreage . l Ownei a Name _vii ':u s�r,� 1t 1 i c . Address i 1',' -_L/)r+ S % r/ (riT(of err 1 /I"Ohone Contractor �n •. `I Address N�. /"�l1r,,t 14 ,1 , 1 S•E 7 License No. Phone TYPE OF WELL/PUMP: NEW WELL.0 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK <("e '` SEWER LINES -7+'-1`• e Z DISPOSAL FLD. PROP. LINE FOUNDATION /d C' r AGRICULTURE WELLALi:- OTHER WELL/A_%«� PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing FI Domenic/Private El Gravel Pack ❑ Tracy Type of Daaing-._�`l_ SpecificationsT_ I'1 Public ❑ Other rl Delta Depth of Grout Seat _zz' Type M Grout 12,r. t• a 1` Q I I Inignion '4j"ApMom. Depth 1 I Eastern Surface Seal Installed by AIAI I Ar ( Repair Work Done ❑ Type of Pump H.P. Slate Work Done Well Destruction ❑ Wall Diameter Sealing Material a Depth s' Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sower is available within 200 lest.) Instaeation will serve: Residence_ Commercial_ Other Number of Owing unite __ Number of bedrooms Z Character of Sol to a depth of 3 feet Wnsefr Atabblle "OfME-��'{� SEPTIC TANK ❑ Type/Mfg Capacity__ Nolfc.py/ 13s PKG. TREATMENT PLT.❑ Msft}ff 6F-4 Distance to poorest: Well foundation Property L{n ,g_.n_lfpD3 ]`� LEACHING LINE Ll No. g Length of lines ._ Total length/s i LO1IAQU 11TN(�; �. ` FILTER BED ❑ Distance to nserast: Well Foundation •_ Pro% IIL �SF [)I�ISIf -- FNVIRONMMACf � SEEPAGE PITS 11 Depth Size Number _ SUMPS 1.1 Distance to rarest: Well _ Foundation Property Line _ DISPOSAL PONDS ❑ t hereby certify that 1 have prepared this application and that the work will be done in accordance with Son Joaquin county ordinances. state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signsturs certifies the following: 'I certify that in the performance or 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 Iowa of California." Contractor's hiring or subcontracting 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 compenaa tion Iowa of California." The applicant fn I call for aR required inspections. Complete drawing onl reverse side. _ Signed X--4-'t 1 1 �rT+ E f�I I Title: ---rL1 1 1+ s� _ Oats: r FO DEPARTMENT USE ONLY �} APMicotbnnAAccepted by — .k— Date Area IA 1" / Pit or rout lhspeetlon by 1J Date 7 � Final Inspection by f; Date Additional Comments: �Q�A /- Z-2 Applirant - Return all 4ples to: San Joaquin Cnunty Public Ilealth Servfces Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE' AMOUNT REMITTED Cg511 RECEIVED BY DATE PERMlf NO. • FN FN r1 H IeEV.v•1,1N or)r _ y7 B `� t�