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APPLICATION FOR PERMIT _ Ski aJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR rROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This 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. lawner.11 Nome .-‘410.joi sipo z% 1)1\414, Address JOS- 3 ii , ke Pt rs.efi 4 jeer • phone 3 N......t Contractor 0 /I Addressar3e3 AL-Jci,,,,,,,64:g&No. Phone WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service WWeeilll SEWER LINES DISPOSAL FLO. 0 OTHER 0 14°r" t°2"1118 ri PROP. LINE SYSTEM REPAIR 0 AGRICULTURE WELL OTHER WELL PITS/SUMPS Job Address d 13$3 City Lot Size/ficreage jc71. TYPE OF WELL/PUMP: NEW WELL 0 PUMP INSTALLATION 0 DISTANCE TO NEAREST: SEPTIC TAN FOUNDATION EA CONSTRUCTI CATIONS T rpe of Grout Sealing Material & Depth Piller Material Si Depth INo septic systerr permitted if public sewer is available within 210 feet .I C-1 No. Si Length of lines 4/0' Toial length/size Y )/ El Distance to nearest: Well I/O" Foundatkm 35— Property Line J çO SEEPAGE PITS I i Depth cac / Size 36.'" Number / r--, / SUMPS LI Distance to nearest: Well /.:2-.5 1 Foundation 7-S- r Property Line / 9c., DISPOSAL PONDS (.3 I hereby Certify 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 whch this permit is issued, I shall not employ any parson in such manner as to become subject to workman's compensation laws of California.- Contractor's hiring or sub-contracting signature certifies the following: "'l certify that in the performance of the work for which this permit is issued, I shall employ perwits subiect to workman's compensa• tion laws of California." The applicant must call for II req red inspecti .sCo lete drawing on reverse side. )14 Title: Well Diameter Depth AYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR (ADDITION. DESTRUCTION C.I Installation will serve: Residence ...SZCommercial _ Other Number of living units' .—I.— Number 01,...,becIro?rna 3 Character of soil to a depth of 3 feet: .%4J1(I nr.t yy% Water table depth ii0 / (...., SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PIT. 0 Method of Jisposal Distance to nearest: Well et.) ' Foundation r Property Line INTENDED USE 0 Industrial LI Domestic/Private 0 Public r...1 Irrigation Repair Work Done Weil DeatructiOn LEACHING LINE FILTER BED TYPE OF WELL PROBL 0 Open Bottom 0 Manteca Cl Gravel Pack 0 Tracy IT] Other 0 Di — Approx. Depth 0 Eastern Type of Pump H.P. D' r ell Excavation e of Casing Grout Seal nstalled by State Work Done Depth Surface Se D a. of Well Casing S >ecifications Date' --1,-Signed X Application Accepted by OR DEPARTMENT USE ONLY Date Final Inspection by Pit or Grout Inspection by Date Additional Comments: 1rd SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERM1T/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO...' MOUNT DUE .... AMOUNT FIEMiTTE0 - C/( I - CASH — RECEIVED sr DATE PERMa NO. , -"'lly,6---0 4 //14.06 7 0/3 timk j_1(/ 9‘1,.... 6 II ( Applicant - Return all copies to: . 13.24 IF1fV. s