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PLICATION FOR PERMIT SAN JOAQUINCOUN" PUBLIC HEALTH SERVICES RECEIVED FN V I ROKMENTAL HEALTH DIVISION NON 9 ?m 1601 F. HAZRLTON AVE. , PHONE. (209)488-3420 P 0 BOX 2009, S71000TON, CA 95201 ENV 1RpWENTAL HEALTH RYTT E2LPIRES 1 Y&R Fc MlfiI kHVIck� (Complete in Triplicate) Application In hereby wide to S•n J-ialuin County for a perttt to cocstr-,ct aro/or install the v•-r s,r,:: e,rrrlt.d. This application Is made in ecoplien,e with San Joaquin County Ordinance no. SL9 and 1862 and the Rut,• aui e•auLtton• or San Joaquin County Public Health 9,rvic,e. Job Address ' 4/ L-0vilbs L/G _ city K5&—C.L_`uri Lot cite, A r,tir.• Owner's Name 1-- -0`4 Address J_ O/ ��.1n1L�1 — P�n�• (S./l49L3 Cont acla f�k 5_ _ ri !1�._Address.�L� �Js•�--t[_"-�censf No. TYPE OF WELL/PUMP NEN WELL ❑ WELL REPLACEMENT iDESTRUCTION 1 U,t of Service Wall L PUMP INSTALLATION I9 SYSTEM REPAIR Ll OTHEP :, si nitcrirtit Well (7 DISTANCE TC NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD _ PRO'' UNE _. FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP!CIFICATIONS Ll Industrial 0 Open Bottom O Manteca Dia.of WN Excavation O's of Was Coarrg 17 ;dDomestK/Private Rl Gravel Pack C]Tracy Type of Cas■v- _._ Soecd catare I'I Public 1 1 Other f)Delta Depth of Grout Seal Type of Grout I I Irfepatron —_- Apiwos. Depth I I Eastern / Surface Seal Installed by Repair Wort Dore U Type of Pump Sr.h___ M.P. ! Slate WoA Done_ Well Destruction O Well D,amatsr 8eallaig Material A Depth Depth_jj Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 111No septic system perma!w if pubi-c sewer is evMlabla%V~200 1041 1 Inatanalionl win wrw: Residence — Conwhorcial_ Other Number of hump units:_ Number of bedrooms Chstwty of sell to a depth of 3 feet: Wner table depth - SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Dhposal Oistanca to nearest: Wen_ Foundation...__ Prop"line---^ 1 LEACHING LINE L-1 No R Length of Imes _ Total length/Ore FILTER SED CI D,stance to novas: Wen Foundation Property lie $1 I _ SEEPAGE PITS 11 Depth __ Sin _ Number SUMPS LI Distance to newt. WON Foundation Property Line DISPOSAL PONDS 0 1 hereby Andy that I have proporsd this application and that the work will be done in accordance wnh San Joaquin county ordinances, stale laws,end rules and regulations of the San Joaquin County M)1141 Owner Or licensed agent's signature certifies the foll~ng: "I Cortlty that in the petlormance Of the wort for which this permit to rested, 1 ehas not ' omploy any potion in ouch manner as to become sublect to workmen's cotrlperaetlon taws of California.-Contrector's hiring Or sub COntroct'ing slgneturO certifies the following:•'I comfy that in the performance of the work for which this permit is iNued,I sties amPfDy Persons subject to workman's cornpenu. tltNl laws of C n4." f TM applK st sal r aI 0qu rad Inspn, ns Compote drawlny sNie I t � Slpr»d K Title: �24'�f Date: _ FOR DOAAT - Application Accepttl by-__- /�� ''•/ / -- - s-- Dn41 : _ Pit or Grout lnepeetbn by -- Date Final Inspection Dy �7� AddNtonel Comments: Applicant - Return all copies to: San Joaquin County PubHe Health 3orviees, Realth Terait/Servless 1601 1. Raseltoo Ave., T 0 2009. Stockton, CA. 93201 FEE AMOUNT Dul AMOUNT REMITTEDRfCIIVlO sCK 0 Y ATE Pip"' l NO INFO __— -3 � tw u N Iaty i f�� r "We••:vtiBrislv•se�h