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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 9520 (209) 468-3447 Complete in Triplicate FAC # M_V # _ co s Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in couplis.nce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7--,373 AVIILL)IA 1 0 7_ S� L Lot Size/Acreage Owner's Name �1 ��1 ('1,',4 Nt5� �Tf %c Address 23 / 31%3C'l 0 5A L? D S-Tel wo I Phone 44 - /06, V L 4�rBiZ�;I o r�U Contractor t L L„z —Address� ; e I- _�_ .LZ4-rvurc r'.�,l��n�ra ��,- 7� License No.C.'< lt<, Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR C OTHER 2 Monitoring Well C,] DISTANCE TO NEAREST: SEPTIC TANK /C0 SEWER LINES Nis _ DISPOSAL FLD. r PROP. LINE FOUNDATION 7C! AGRICULTURE WELL L�L_ OTHER WELL '•>C'' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation ” Dia. of Well Casing A!drt-<- U Domestic/Private O Gravel Pack ❑ Tracy Type of Casing i(�l/a Specifications / ID Public Cl Other `' O Delta Depth of Grout Seal �,( rE�i^AC E_— Type of Grout Ctir I� M luiUation [S L, Approx. Depth a Eastern Surface Saul Installed by Repair Work Done U Type of Pump H.P. . State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted it public sewer is available within 200 test.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _Water fable depth PKG. TREATMENT PLT. SEPTIC TANK O Type/Mfg Capacity_ No. Compartments O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines _ Total length/size FILTER BED I.) Distance to nearest: Well Foundation Propeny Line SEEPAGE PITS 11 Depth Sire — _ Number SUMPS Ll Distance to nearest: Well Foundation , Property Line DISPOSAL PONOS O - - - -- Iry �o •� • .•w rear rrre wurK wul ue oone in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I cenify that in the periormance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub -contracting signature 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• tion laws of.Californla." The applicant /mu c or all r quired inspections. Complete drawing /on reverse side. Signed !v {� / Title: L•tt'T5L%LT/aim T Dale: FOR DEPARTMENT USE ONLY Application Accepted by , - / Q D ate Pit or Grout Inspection by - Additional Comments _ Date r a Final Inspection by Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C S ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009. STOCKTON ca at3m--_ N IREV. iin01 EH :r.m FEE NFO AMOUNT DUE AMOUNT REMITTEO CK If CASH RECEIVED 8Y GATE PERMIT N0.