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APPLICATION FOR PERMIT t y VA_ SAN JOAQUIN ENVIRONMENTAL HEALTH AI SERVICES I COUNTY DIVISION ON k P O BOX 2009, STOCKTON, CA 95201 S'qN (209) 468--37,3`��O �NVPUB(/�pApU/ ��91 PPtiR1ITT EXPIRES I YTs a�� RCNMENTTH E�Nry f (Complete in Triplicate) l`E,q�TRV��16,',, Application is hereby made to San Joaquin County for a permit to construct and/or install the work- herein descriaggshis I application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of—SLn j Joaquin County Public Health Services, r� r r �_ _ _APW^ APAJ 201-04"Og I' ¢'^� Job Address City MAN" Lot Size/Acreage Z.10 C. I �� Owner's Name V6L1 CATo 1 re Address 12.661, 5 a te--— �Q one Z' 16W VaRbic0i ST., $15 7 Contractor_EAIQYH�EC, LIP, Address License No. AnR 575_Phone I TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well G7 ,fit,,, M to Il C9, PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER Yet�v DISTANCE TO NEAREST: SEPTIC TANK A Mr _f _. SEWER LINES me" DISPOSAL FLD. 'A~ PROP. LINE FOUNDATION NJ!Lk� AGRICULTURE WELL _Afte--- OTHER WELL!yB& •, PITS/SUMPSNLone INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOhl i f_7 Industrial ❑ Open ]Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LJ Domestit:/Privals ❑ Gravel Pack ❑ Tracy Type of Casing ...... Specifications II Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout M Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. I Stale Work Done Well Destruction ❑ Well Diameter Sealing Material 4 Depth Depth Filler Material i Depth TYPE Of SEPTIC WORK: NEW INSTALLATION❑ . REPAIR/ADDITION 0 DESTRUCTION G iNailable sept within m l mitted it public sower is etA Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C] Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line � DISPOSAL PONDS 0 - -- m � .,_ I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin 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 subcontracting 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• t tion laws of California." The applicant must taZ=:�Z= plete drawing on reverse side. �Signed X � Title: x!A! Date: r. FO DE RTMENT USE ONLY I Applicstion Accepted by Date _ Area Pit Grout In scion by Date Final Inspection by Date Additional Comments- Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOR 2009, STOCKTON, CA 95201 EEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT'NO. INFO . EH 13.24[REV. i r 57 Q -� n q EH',4.26