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APPLICATION ., JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009 , STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (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 is made in compliance with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services Job Address _c � tel_/V.li�1`11/1l ,i' ?'T ��/� C,ry %✓ Lot Size/Acreage `` 4ajGL i a�ray+:. / E Owners Name Y��/�l>� t�CEY�trQ.J.'C+�gddress N i��'�CSL�.� ��. A Phonel�ci�r)�15 —�[ �_1 Contractor fT/4'NG%'__ �?0--Z—C f6!ZZ2'y4ddress!G�'yl �>��e�; ALO �'r7 License No lc7'- 25L Ph e e!52— TYPE OF WELL/PUMP NEW WELD WELL REPLACEMENT n DESTRUCTION O Out of service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ITHER O Monitoring Well DISTANCE TO NEAREST SEPTIC TANK SEWER LINES<,�4'rNftrr'3 P SAL FLO PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /`IGwTL'rc- ❑ Open Bottom ❑ Manteca Dia of Well Excavatwn_ Dia of Well Casing •C I Domestic/Private L�Gravef Pack OT y Type of Casing_ r r/ Specifications I I Public 11 other elle Depth of Grout Seal " r p Type of Grout I I Irrivation -JOApprox Depth I t Eastern Surface Seal Installed by Repan Work Done U Type of Pump H P State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 4 Depth Depth biller Material A Depth TYPE OF SEP WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system perimfled it public rower is available within 2p@'teat 1 Installation will se Residence _ Commercial— Other Number of living units Number of bedrooms Character of rod to a depth o set Water table depth SEPTIC TANK ❑ Type/ Capactty No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well F anon Property Line LEACHING LINE Cl No b Length of lines Total length/size FILTER BED 0 Distance to nearest elfdation Property Line SEEPAGE PITS 11 Depth Size mbar SUMPS LI lance to nearest Well Foundation my Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances slate laws and rules and regulations of the San Joaquin County Home owner or Itcensed agent s signature certifies 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 compenza tion laws of Caiifornre ' The applicant must call for all all,required inspections �7Complete `drraawing J)s revetsat side / f Signed X_rw---Q' ""_i. � 33 _k? --��"�tr d` tl[�(+2� I ccsa�.a � Date 1! f . FOR DEPARTMENT USE ONLY Apphcation Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments Applicant -- Return all copies to San Joaquin County Public Health Services Environmental Health Permit/services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK i RECEIVED BY DATE PERMIT NO EH 13.24 It1Ew 1r44S0 914 14 29