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a�tia�b� APPLICATION r,, --- - --- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVTCES� # _ 3� Q' ENVIRONMENTAL HEALTH DIVISION r .0 # V �/ 445 N SAN JOAQUIN , PHONE ( 209 ) 46$-34 P O BO% 2009, STOCKTON, CA 95201 I' �, # � PERMIT EXPIRES 1:YEAR FROM DATE ISS RD."/ # fn� (Complete in Triplicate) --! Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in compliance vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of Evan Joaquin County Nblicc� I ` W 7� � Health Services. / / IAMA,^— . /�-�� q w.4 V ro.� 79PXV—U Lot Size/Acreage .-r --v wwr P nate pe eperuo iris applrcarlon ano tnat the work Will be done in accordance with Safi JoaQuin County ordinances, state Daws, and rules and regulations of the San Joaquin County HOMO owner or kcensod agent's signature oertilies the following; "I certify that in the performance of the work IG4 which this permit is issued, I shall not employ any person in such manner as to become subject to wArkman's compensation laws of California." Contractus hiring or sub -contracting signature certifies the following: "I certify It -,at in the performance of the work for which Ihis punt is issued, I shall employ peran4 subject to workmen's cnmpenss• tion lows of California." The applicant muni call ild in coons. Complete drawing on rev��erserrs��ide��, Signed K 41 __ Title:C,rt...fAit�f� Date: _ i^ FOR DEPARTMENT USE ONLY Application Accapted by t� y . _ Date Ct Area , Pio or Grout inlipeCtion by Date Final Inspection by Date Additional Comments: , Applicnnt p Return all copies to ill 13-N INE`/. I / N 5 tM 14-25 r-- Ban Joaquin County Public Health Servlce1 Savironmental Health Permit/Services 445 N San Joaquin, P Q Box 2009, St", C;:'95201 � 1 INfOlfEE - - v / Owner's Name �� DAT Address _ Phone Contractor g4 AJ -� � Address �i / �a� P,,,(/ a� License Nor4d Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT C1 DESTPUCTION ❑ Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER G monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER VVELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl industrial ❑ Open Bottom L-3. Manteca D;a of Well Excavation, Dia. of Well Casing Fl Domestic/Private Cl Gravel Pack O Tracy Type of Casing_ - Specifications - 1'1 Public 1-1 Other (l Delia Depth of Grout SeaA I I frfigation ,__ Approx. Depth I I Eastarn Surface Saul Installed by. ■ �� Repair Work Done U Type of Pump H.P- -_, State Work Done RECEIVED Well Destruction CI Well Diameter Sealina Not:erial k Depth AN a �a '�7� Depth Pillar MateriaDepth l A TYPE OF SEPTIC WORK, NEW INSTALLATION REPAIR/ ADD: TION 1 1 DESTRUCTION I i (No septr ' �Fqi5` er is a1ella IFi'1 HEALTH Installation will serve: 1If�l O1MON Commercial _ Other � • Residence -LI Number of living units: l— Number of bedrooms 3 Character of soil to a depth of 3 feet; /l ogs 79 ... Water table depth SEPTIC TANK - ❑ Type/Mfg -e CsPaclay/6&C2 No. Compartinnonta PKG. TREATMENT PLT. ❑ Distance to nearest: _ Method of Disposal —�VeI4WIift4Foundation %d f T Property Line LEACHING LINE Cl No. b Length of lines � - 4-O-- ?length/size— length/si• �0 FILTER FILTER BED CI Distance to nearest: Wef /y� Foundation A Property Line SEEPAGE PITS I I Depth��N,.�um-._ber SUMPS VC Distance to nearest: We Foundation 5��! Property Line DISPOSAL PONDS Cl .-r --v wwr P nate pe eperuo iris applrcarlon ano tnat the work Will be done in accordance with Safi JoaQuin County ordinances, state Daws, and rules and regulations of the San Joaquin County HOMO owner or kcensod agent's signature oertilies the following; "I certify that in the performance of the work IG4 which this permit is issued, I shall not employ any person in such manner as to become subject to wArkman's compensation laws of California." Contractus hiring or sub -contracting signature certifies the following: "I certify It -,at in the performance of the work for which Ihis punt is issued, I shall employ peran4 subject to workmen's cnmpenss• tion lows of California." The applicant muni call ild in coons. Complete drawing on rev��erserrs��ide��, Signed K 41 __ Title:C,rt...fAit�f� Date: _ i^ FOR DEPARTMENT USE ONLY Application Accapted by t� y . _ Date Ct Area , Pio or Grout inlipeCtion by Date Final Inspection by Date Additional Comments: , Applicnnt p Return all copies to ill 13-N INE`/. I / N 5 tM 14-25 r-- Ban Joaquin County Public Health Servlce1 Savironmental Health Permit/Services 445 N San Joaquin, P Q Box 2009, St", C;:'95201 � 1 INfOlfEE AMOUNT DOE AMOUNT REMITTED ASH RECEIVED BY DAT b-l_q