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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES > owy," ,,y,�, ENVIRONMENTAL HEALTH DIVISION d P O BOX 2009, STOCKTON, CA 95201 f (209) 468-3447 YEAR VRQM DATE ISSUED,, (Complete in Triplicate) ° Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This ' application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County rPublic Health Services. VJob Address 7i A0 WA '° City 9�cAnm/Lot Size/Acreage 10, �} Owner's Name �� ' J F t'hAddress ,��`�� c '�Gy/7 Phone Contractc� Address !/ F`�IrL?/V /�-f License No. Phone �'A7f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [7 DESTRUCTION ❑ Out of Service Well ❑ PUMP !NS TION ❑ SYSTEM REPAIR ❑ 07HER ❑ Mo ring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, LINE FOUNDATION CULTURE WELL OLHER WEL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUC7lOfV ATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. o xcavation pia. of Well Casing Cl Domestic/Private 0 Gravel Pack . 0 Tracy ype of Caain Specifications �] 0 Public 1-1 Other 0 Depth of Grout Seal Type of Grout �,. M Irrigation ' �. Approx, D 0 Eastern Surface Saul Installed by 1, Repair Work Done 0 T mp H.P. State Work Well Destru Well Diameter Seali rntl . f Depth Fille e_r MTtx LIN2 r TYPE OF SEPTIC WORK: NEW INSTALLATION L] REPAIRIADDITION 1`I ESTRU TIO I ;gF4�r rmitted it public sewer is Permit may hav giFabOe'Wr i feet.} / rinstallation will serve: Residence Commercial____, Other� Orrtpleted Or inspected Number of living units: Numberrof bedrooms i + Character of axil to a depth of 3 feet: :° rn rim tal Health„ V13101pth er taDle SEPTIC TANK- ❑ Type/Mfg Capacity_ No, Compartments PKG. TREATMENT PLT. C1E Method of Disposal i Distance to nearest: Well Foundation Property Line + ,. x t LEACHING LINE ❑ No. & Length of lines 4¢ Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ul{ Distance to nearest: Welt Foundation Property Line Vr.\ DISPOSAL PONDS ❑ I hereby cenify that h have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Saii'.oaquin County Home owner or licensed agent's signature cenifies 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 laws of California." Contractor's hiring or sub-contracting signature —...cenifies 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- tion laws of alifornlp. The appG must coil for all Ira p6eT"--complete drawing on r arse side. r Signed 7Z/ ,t e. Gf�N.E Date: f 1n ;le- w r' R DEPARTMENT USE ONLY Application Accepted by 6�LDate t�U` 9 Arae Pit at'-Grout Inspection by Date Final Inspection by Data Additional Comments: } _ i Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES r 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED MASH RECEIVED BY DATE PERMIT'NO. . EH 13.24 tREV.I/it ^/a •+'JJ,1 r.o �.