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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • I . ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i 4 (Complete in Triplicate) Application is hereby msde,to San Joaquin County for a Permit to construct and/or install the vork herein described. This application is meds in ecapliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Publie,Healtb Services. ,,/ /7 q Job Address �v/JtV923J �Z - 7` 1,zz_� �[_ City A� + Lot Stu/Acreage owner's Name &0 j,/f/3L l�Y � Phone �g Address/1 ? ,5/,, N Contractor J I Address ��7 license NcW �� Phone —'•'ff t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL KD. PROP. LINE FOUNDATIONT AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑-opo- ❑ Manteca Dia. of Well Excavation Oto. of Wall Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public In Other n Data Depth of Grout Seal Type of Grout I I irrigation —Approx. Depth I I Eastern Surface Saul Installed by Rape's Work Dom ❑ Type of Pune f - M.P. State Work Done_ VJ WaR Destruction ❑ Won Diameter + 11ug'Ifat+riar 1 a Depth , Depth Piller Material i Depth i •TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ,.DESTRUCTION I I (No sepltc system pwrniped if public rower is C '-a available within 200 feet.) k Installation will serve: Residence_ Commercial Other - r✓ s+f�c� j Numbs of kvwq units: _ Number of bedrooms - Character of sole 10 a depth of 3 fest: '(Xaq - - r Water table depth SEPTIC TANK. e-Type/M4 CP2+:2 t - (0 V4—' Capacity No. Compartntenta I PKG.TREATMENT PLT. ❑ r Matted of Disposal Distance to nserest: Well Founds Property Property Lim i LEACHING LINE No. g Length et•lima l Total length/size / ! FILTER SED 9' Distance to Xnsaeat: Well 70 Foundation Property Lim SEEPAGE PITS I-KDepth o25 / Size n Number SUMPS LI Distance to rte m: Weil 0 r Foundation 42� Property L"uhe 2 DISPOSAL PONDS ❑ r;t hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sate tows, and rules and regulations of the San Joaquin CCN°Lz' Homs owner or liumed Amens signature certifies the following: 91 certify that in ths'performance of the work for which this permit is issued, 1 shall not anMloY any psrton in such manner a tei)eeoirq subject to workman's compensation Laws of Calilorrus."Contractor's hiring or sub-contracting signature CMilip the following:"I codify that in the performance of the work for which thin petmit is issued,1 snall employ persons subJsct to workman i compenso- h tion I""Of CaiforNe." ',I r The cam or riR� urnspioti". Complete drawing on remorse side. signed x t'-:�5� Title: 4!!5'L(k9'C - Date: y/ i/ / FSO.R DEPARTMENT USE ONLY !1 Appbcatbn Accepted by:.:V ,,40 - . .Dais �3 Arae_ t o[ s a . Ph or Grout Inspection by - Qalo Finitl Inspection D e Additional Coenw, -� �. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/aervlcee i 44S N San Josquin,�P 0 Box 2009, Slits, CA 95201 • j FEE AMOUNT DUE AMOUNT REMITTED EtEIVE BY D TE PERMIT NO. IN/F�O • fA i4M(REV.tract II f/�jL(i�/ ! ' .�j �9 `� ✓ '�� /_ t