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APPLICATION FOR PER-MIT �p - - 1 J - 1 SAN JOAQUIN COUNTY PUBLIC aEAL'IZA 'H V6 ENVIRONMENTAL HEALTH DIYISI i> � P O BOX 2009 , STOCKTON, CA 9 (209) 468 '342-0 e AA R PROM D (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein ascribed. 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 Seryices. L1 Al Ci7-y f�r?ry/>E�Ty— ,4^J ,v,,r ,�. /-1-tv'o DA QQ E. /�A 1� 5 f.• City STOCI<TTOAJ Lot Site/Acreage 4 IA. �� Joh Address Q� b1ts1 Owner's Name r7NDftELV Ll'q D U1YF Address P.o.13ox 523 Phone 9 - 3 j2A"c 14 Pie. Contraclor 1 kbrll Dr>I Address P4.130X z 231 CeQnoJA `574/ License No.G 7ZG/ 7 Phone- TYPE hone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION Cl Out of Service well Cl PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER JKMonitoring Well {� 13o2i.�/'r DISTANCE TO NEAREST: SEPTIC TANK teV//-1 SEWER LINES 5_0 r DISPOSAL FLD.lAll,_ PROP. LINE _S, FOUNDATION �3AGRICULTURE WELLOTHER WELL ZY PITS/SUMPS L'✓1'd INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation " Dia. of Well Casing A111 - &Domestic/Private C) Gravel Pack L7 Tracy Type of Casing No.NE Specifications ID Public jrf Other O Delta Depth of Grout Seal 5.V_$Fr9-,C-jfType of Grout f'E!+GA/f CI Irrigation �Q.Approx. Depth ❑ Eastern Surface Seal Installed by-_CoyyQAGToit Repair Work Done U Type of Pump N.P. _ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth VV Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION CI DESTRUCTION CI (No septic system permitted if public sewer is Cy available within 200 feet.) Installation will serve: Residence _ Commercial_ Other _ p M Number of living units: Number of bedrooms PAYMENT ♦ `) Character of soil to a depth of 3 feet: Wi; de SEPTIC TANK ❑ Type/Mfg Capacity_ 1� m�arfrJne�lF`��__ PKG. TREATMENT PLT, Cl e o of Disposal 51��_PO,I �? ll�l rr)t!1 y Distance to nearest: Well Foundation P{hj 1, ly o?-1` --'r— ,-- ( S LEACHING LINE Cl No. b Length of lines _ Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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: "1 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 workmen's compensation laws 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 compensa- tion lawn of California." The applicant call f r all required inspections. Complete drawing on reverse side. Signed l/"• TitIa: �sr A-' Date:FOR DEPARTMENT USE ONLY �j p• �j^_ Application Accepted by Data Jam! Area " � Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 1 y Applicant — Return L11. copies to: SAN J UIN COUNTY PUBLIC HEALTH SERV CES HEALTH DIVISION PERMIT/SERVICES ( (0 I /445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 `P ; 1INFOFEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERM17 N0. f— FNVIRONIdENTAL ��1 • EN13:4.2 IRfV.1/n5! 10(/1 EH :�.� (��J �(f 1 ��!/ Il'J!✓1lnY U �! (L� ` l( r