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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH S • , ENVIRONMENTAL HEALTH p I V I S I 445 N SAN JOAQUIN, PHONE (209)46 P O BOX 2009, STOCKTON, CA 952,01. PERMIT EXPIRES 1 YEAR FROM DATE (Complete in Triplicate) p p ) ApPlication is hereby made to San Joaquin County for a Permit to construct and/or install the vont herein described. This application is Made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Fcegulations of San Joaquin County Public Health Setwiees. ZU-17--4� Job Address City Lot Size/Acreage f -• V COMIr rner 1 neve prepared tnls application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County Home owner of hConaed agent's eign,luro conif*s the following: "I certify that in the paifoimance of the work for which this permit is issued, I shall not employ any person in such n'lanner "to become subject to workman's compensal ion tawsof California." Contractcr's hiring or sub -contracting signature cartifiss this following: "I certify that in the performance of the work for which this permit is issued, I shall employ parscna subject to workman's compensa- tion laws of California." The applicant must CAN for Al!pquirsd inspections. Complete drawing on reverse side. Signed i _ Title: Dow- FOR ata FOR DEPARTMENT USE ONLY Application Accepted by Data �' Area , 1Y1�.[.1^ (lW Pit ct Grout Inspection by jy•�1 �� ,, ,� Date Final Inspection by �• Dete Additional Comments: __AQ,. f11! dt.,a 1 D s,n Applicant - Return all copies to EM 13-24 NILV,. fN 1419 9Y x t� S•) O San Joaquin county Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stk.,CA 201,/} h O INFO AMOUNT DUE Owner's NameFZS — Address __, SIJ %i�AC�— Phone Contractor rid ALIJLL T Address cC7r � .r�m4co t� License No. oz/QST—� Phone g26 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT aD DESTrfUCTION D Out of Service Weil D PUMP INS T ALLATION C SYSTEM REPAIR D OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —^ DISPOSAL fLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER;lit/ELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation �T Oia. of Well Casing f.I OomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of C_aaint" t ^' $*ifcatilxis VI Public 1-1 Other 1-1 Delta Depth of Grout Sew Typo of Grout I Irrigation _ Aptxox. Depth I I Eamern- Surface Seal Installed by RAvuram Repair Work Done U Type of Pump H. P. _ State Work Gone Well Destruction D Well Diameter Saaling Material i Depth Depth Filler Material 4 Depth AIN RAM TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION I I DESTRUCTION.1 I [No seplr %� sewer is wj��i Installation will serve; aysilabfp SERVICES Re9ilyence _ Commercial _ Orl+er =[t,rltttlNMEN7A! HEALTH DIVISION Y Number of living units: __ Number of bedrooms Character of loll to a depth of 3 feet: _Water table depth SEPTIC TANK D Typelmig P -r< �� Car�acity_ /fs6(� No! Cornparlmsnts °KG. TREATMENT PLT. Cl Method of Ditlposal Distance to nearest: Well t Foundation iT Property Line` _EACHING LINE C1 No. b Length of lines _ �T Total lengthfeize 'ILTER BED Ci Distance to nearest: WaNdQt!M�,�Foundation Property Lk►e >EEPAGE PITS I I Depth O %T §iie 'W � 16 Y !O Number iUMPS Distance to nearest: Welter cundation Oar Pre4*rty Line �ja 1� )ISPOSAL PONDS 0 1 -• V COMIr rner 1 neve prepared tnls application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County Home owner of hConaed agent's eign,luro conif*s the following: "I certify that in the paifoimance of the work for which this permit is issued, I shall not employ any person in such n'lanner "to become subject to workman's compensal ion tawsof California." Contractcr's hiring or sub -contracting signature cartifiss this following: "I certify that in the performance of the work for which this permit is issued, I shall employ parscna subject to workman's compensa- tion laws of California." The applicant must CAN for Al!pquirsd inspections. Complete drawing on reverse side. Signed i _ Title: Dow- FOR ata FOR DEPARTMENT USE ONLY Application Accepted by Data �' Area , 1Y1�.[.1^ (lW Pit ct Grout Inspection by jy•�1 �� ,, ,� Date Final Inspection by �• Dete Additional Comments: __AQ,. f11! dt.,a 1 D s,n Applicant - Return all copies to EM 13-24 NILV,. fN 1419 9Y x t� S•) O San Joaquin county Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stk.,CA 201,/} h O INFO AMOUNT DUE AM OUNT REMfT'TEO CK RECEIVED ' H ZFEE