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APPLICATION FOR PERMIT <br /> Y. SAN JOAQUIN COUNTY PUBLIC HEALTH §'ERVICES 4--,f <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. .11AZELTON AVE. , PHONE (209)468-3420 JA i <br /> P 0 BOX 2009, STOC[TON, CA 95201 <br /> ­ <br /> PERMIT EXPIRES I YEAR F99M DATE ISSUED 0 <br /> (Complete in T,iplicate) <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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Rcigulationa of San <br /> Joaquin County Public Health Services. <br /> Job Address M'�6 City Lot Size/Acreage <br /> ,49 APhone <br /> - <br /> Owner's Name 14U4 Isfers JV4 %"40 Id,3� Address __ Q 1, ja,�Wc_& ---- <br /> //yo/ 1'4,1�,qrql� c 5r7 <br /> Contractor anofjiowk 7e-c&.A^�Adid,,Sg 'Q,SQ-"ioL�4 License No. AW 7, <br /> 0 Ph,n a <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLA EMENT 0 DESTRUCTION 0 Out of Service Well D <br /> PUMP INSTALLATION [I SYSTEMIJEPAIR D OTHER Me it ring Well <br /> 4 sa i r) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE --:— <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> U TIO <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU TION SPECIFICATIONS <br /> 11 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of We Casing <br /> U Domestic/Private El Gravel Pack 9-Tracy Type of C;sing I Specifications <br /> A <br /> Public [Other F1 Delta Depth of C rout Seal Type of Grout <br /> t I Irrigation AeApprox. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction C3 Well Diameter Sealing Material 1111; Depth JM2tej�e <br /> Depth Filler Hateirial & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: — Number of bedrooms <br /> Character of sell to a depth of j feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Ca acity No. Corhp6rtmenti <br /> PKG. TREATMENT PLT,0 Method of Diiposal <br /> Distance to nearest: Well Foundation— Property Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Founds ion — Property Line <br /> SEEPAGE PITS 11 Depth Size —, Number <br /> SUMPS Cl Distance to nearest- Well Founds i ion— Property Line <br /> DISPOSAL PONDS El <br /> 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 <br /> rules and regulations of the Son Joaquin County <br /> 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 <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 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must cslljrr all required Inspections. Complete drawing on reverse side, <br /> C2� <br /> Signed X st� 'Title: ' U�- Dale: <br /> FOR DEPAR�tMENT 'USE ONd <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> P <br /> Additional Comments: 1 w '7 <br /> Applicant - Return all copies to: San Joagin County Public Healt I <br /> Services, Environmental Health Peradt/Services <br /> 1601 E. Hazelton Ave".. P 0 Box 009, Stockton, CA 95201 <br /> K <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> 4P 0 <br /> 0'r- - c * ' <br /> Lf __0 - c — <br /> 1H 13-24 1111V.I W <br /> CH 14 M Z37 ;"111 11 - <br /> -20 'ik <br />