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!, - APPL I CATION FOR- PERM I T <br /> SAN Jo <br /> r COUNTY PUBLIC HEALTH SE <br /> ENVIRONILWTAL HEALTa DIVISION <br /> P 0 BOX 2009, STOCKTON., CA 95201 <br /> (209) 468-3447 <br /> I, PERMIT U21-UH- I. YEAR 1�kR_M_J)ATS_1SSUFiD <br /> : (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance`with San Joaquin County ordinance'No. 549 and 1862 amd the Rules and Regulations of San <br /> Joaquin?County Public Health Services <br /> Job Add�r ss Z!1 /1 Sa ra Lot Size/Acreage <br /> A��.�I 5. Sou.z Address 3��• Mn S.,;4,0 /Ya Phone 5-83 a <br /> Owner's Name — `� <br /> �j -� ZSZS �. N�yr 5 rzz 8 <br /> i <br /> Contractor_�eG t W4_,+n Address f'._-——License too, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Out of Service well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR y OTHER ❑ Monitoring well <br /> 0 � t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLO. - PROP. LINE <br /> �{ FOUNDATION AGRICULTURE`HELL i OTHER WELL PITS/SUMPS <br /> INTENDED USE ;TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS Pl-e556A re <br /> Cr Industrial L7 Open Bottom 0 Manteca _ Dia. of Wail Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing 11 L Specifications <br /> M PubGc!' {"1 Other `� D Delta Depth of Groyt .Seal Type of Groutcm eE <br /> 0 IrrrOation Approx.�!Depth ❑ Eastern Surface Se6l Installed by <br /> Repair Worst Done U Type of Pump H.P. Stats Work Done <br /> Well Destruction O Welt Diameter Sealing t+laterial A Depth <br /> Depth Filler Mtaterial 4,Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200ftiv <br /> Installation will serve. Rtiiidence :I Commercial— Other <br /> p IIS <br /> Number�� of living units: Number of bedrooms f RECEIVED iE <br /> Character of soil to a depth of 3 feet: , Water table ds <br /> fs , <br /> SEPTIC TANK ❑'` Type/Mfg� Capacity No. Comp s r <br /> PKG. TREATMENT PLT.0: � ������ � "~ r `' l' <br /> r � Mletho � �• <br /> Distance to nearest: Well Foundation ! Property L'�t��r" ��j ��H�I`i l <br /> LEACHING LINE ❑ No. b Length of lines `I' _ Total length/size L <br /> FILTER BEO ❑. Distance to nearest: Weil Foundation Property Line CF } <br /> SEEPAGE PITS i I Depth '+ Size Number <br /> SUMPS] ll.I Distance to nearest: Weil Foundation Property Lina I <br /> DISPOSAL PONDS ❑' ll jj' s <br /> I hereby:eertify that I have prepared this,application and that the work will be done in'accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: 1 certify that in she performance of the work for which this permit is issued, t shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall ampto erSoria suy9: // <br /> orkman's compensa- <br /> tion laws;_of California." PO <br /> The appl At $t call for all r quirad in pec s. Complete drawing on reverse side. <br /> Signet Title: 9 <br /> �'e Ci [ FOR DEPARTMENT USE ONLY <br /> Application Accepted by tv, Ad �' ' —_ Date Area <br /> Pit or G out Inspection b Data Final Inspection by Date C <br /> FV <br /> Additional Comntanta: <br /> Applicant — Return all,:,copies. to SAN JOAQUIN C UNTY PUBLIC LTH SERVICES <br /> l I ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> U 445 N SAN JOAQUIN, P O B 009, STOCKTON, CA 95201 Z-11 � <br /> IFEE <br /> NFO AMOUNT DUE li AMOUNT REMITTED CK J ! CEIV£D Sy OATS PERMIT NO. <br /> EH,3.2.IilkEV.I,�,r �a0.� �; BOO• 2aS ?l�'°J 9%-0/Z <br />