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{ APPLICATION FOR PERMIT <br /> SAN Y� /`@UIN COUNTY PUBLIC HEALTH}vices PAYMENT <br /> / �6NVIRONNRNTAL HEALTH DIVISI6101" RECEIVED <br /> 445 N SAN JOAQUIN, PHONE (209)468-34201 <br /> FEB 10 1 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> SAN JOAQUIN EpUNTY <br /> PERMIT WIRES 1 YEAR FROM DATE ISR PUBLIC HtAtjti SERVICV.S <br /> kcOmplete in Triplicate) rnVIR0I4MENTALHEALTHDIVISION <br /> Application is hereby node to Ban Joaquin county for a permit to construct and/or install the vork herein described. This <br /> application is mode in ecwpllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and:Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address - E . {-1 <br /> �or.1 Vyh. City .�'TOCte,J Lot Size/Acreage <br /> } _t "'I" CwOwners Name /bS , . 1Address j= \AtgJ <br /> rA, one LO <br /> ( .LAY. IDI"sf1D"T - _L i r <br /> contractor___ v%j .Lq-5 Address <br /> License Nr i _�—?hone_ <br /> ;I <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT O DESTRUCTION ❑ Out oT 8 ce W <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O . eitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES .Ser Cr DISPOSAL FLO. -� PROP,. LIN J <br /> FOUNDATION AGRICULTURE WELL OTHER WELL /� PITS%SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'I ` <br /> 171 Indmtrial ❑ Open Bottom O Manteca Die. of Well Excavation Dia. of Well Coming <br /> t <br /> Amestie r Ta a .�Orsvel Peek 0 Tracy Type et casing ?ACrg SLS ia'4 a. Specifications1 <br /> Il Public O rout 01 r fl Delta Depth of GSeal J �-�0 P6i� Type ypa of 'Grout �'=�TO",T-r_ <br /> I I hrion6on. *W pox. Depth I I Eastern Surface Seal Installed by -'OFAL. z�✓T MN <br /> Repair Work Done O Type of Pump H'.P. Stats Work Dona_ _C <br /> Well Destruction O We" Diameter c Sealing Material a Depth ' ^ <br /> Depth 1 ' Tiller Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system Permitted it public sewer is <br /> available within 200 feed <br /> B <br /> Inslaation win serve: Residence_ Commercial_ Other ) <br /> Number of living units. _ Number of bedrooms —"� <br /> Character of soil to a depth of 3 feet: <br /> Water tabs depth <br /> SEPTIC TANK. ❑ Typs/Mfg _ �— Capacity No. Compartments A <br /> PKG. TREATMENT PLY.❑ Method of Disposal, <br /> nes to nearest: Well Foundation Property Line <br /> LEACHFILTER BE LINE O Distance <br /> 8 Length of lined 7ota1 len th/Nse— ? <br /> FILTER BED O Distance to nearest: Well Fou d�Property Line r <br /> SEEPAGE PITS I I Depth Size - - Number <br /> SUMPS JI I.e anu to rMarast: i,Well Foundation Property Lint <br /> DISPOSAL PON QS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, nate awe, and <br /> rules and regulations of the San Joaquin County ; <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work f � <br /> or wI which this permit la issued, I shell not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or daub-contracting signature <br /> conifies the following:"I certify that in the psAormance of the work for which this permit is issued,I shall employ persons subject to workman's comport. <br /> tion laws of Coliforriia." <br /> The applkaaJJ\a1�( st a 11 for I required Inspections. Complete drawing on reverse side. <br /> Signed Title: 4 6-ep o6�S�� � ..~Dole: I <br /> FOR DEPARTMENT USE ONLY 1-�— LOP <br /> Application Aceepted by C� Date 3 Area <br /> Pit or Grout Inspection by Oate Fine$ Inspection by Data <br /> Additional Comments: W��/ v 6, S A 'M <br /> . Applicant - Return all co Sea to: San Joaquin County Public Health Services �I <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> i. <br /> FEE <br /> NFO AMOUNT DUE AMOUNT REMIT-TED CASH RECEIVED BY r^c�, OATE�'� PERMIT'N?Oo <br /> . EN fi 24(REV.rra Site <br /> it <br /> Ikie <br /> 4 <br /> I <br />