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APPLICATION FOR PERMIT SAN JOAVIN COUNTY PUBLIC HEALTH SERVIcCES ENVIRONBENTAL HEALTH DIVISION g 445 N SAN JOAQUIN, PHONE (209)458-3420 P O BOX 2009, STOCKTON, CA 95201 O C>e/��.D PERMIT EXPIRES 1 YEAR FROM DATE issuEDSA/��CT 3 0 egg (Complete in Triplicate) ENS US(IC0,4ot,W,. Z Application is hereby made.to San Joaquin County for a permit to construct and/or install the voF n�p#' O. This application is made in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and Lhe Rules and 0 San Joaquin County Public Health Services. �,! ��(��(VVVVVV/JJUN Job Address 11`/0 �a✓I/ 4,Ile- City ,Sfoc/;X0-7 Lot Size/Acreage LT IF -zcyGS Owner's Name r �n sccu/ of 41�1(_ Address �� `�Y l/ir✓e Phone 09 5��571 , / !f 3233 %f*�� i, / S/7 Contractor /e.S `4Zo' O1 Address R�*�D Cor ✓cz L . �`r2 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT rl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER Z'Stn L�r�ng H�11 O DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES �4,2f DISPOSAL FLD. A1A PROP. LINE _4 t Cr Lon/es/Xj• .as lr � FOUNDATION AGRICULTURE WELL � OTHER WELL PITS/SUMPS INTE DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t I Domestic/Ptivato ❑ Gravel Pack O Tracy Type of Casing Specifications I1 Public fl Other rl Delta Depth of Grout Seal Typo of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done — N Welf Destruction O Well Diameter Sealing Material i Depth w Depth Filler Material b Depth JV1� TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commerciat_ Other Number of living units: Number of bedrooms— i Character of coif to a depth of 3 fact: Water table depth SEPTIC TANK. O Typo/Mfg Capacity No. Compartmants PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Wall Foundation Property Line r LEACHING LINE 0 No. 8 Length of limes Total length/sizo FILTER BED O Distance to nearest: Well Foundation Property SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Propo DISPOSAL PONDS O 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 which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following: "I conify that in tho performance of the work for which this permit is issued,I shall employ persons subject to workman's componsa- tion laws of California... The applica st call for atl required inspections. Complete drawing on reverse side. ��Signed Title: �` Date: ezi�� FOR DEPARTMENT USE ONLY Application Accepted by Date\ Area Pit or Grout inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �� Environmental Health Permit/Services UO 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE S INFO AMOUNT DUE AMOUNT REMITTED ASH R CEtVED BY DATE PERMIT,NO. . EM1}2tlAEV.1/piti1 /�EM 14-2 89.0-0 10+0 �O3-02.