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w` APPLICATION FOR PERMIT f� _ SAN JOAQOIN COUNTY PUBLIC HEALTH SErv -- S#ENVIRONMENTAL HEALTH DIVISIO P O BO% 2009, STOCKTON, CA 952D # (209) 468-3447 2LUTT Mir i (Complete is Triplicate) r # �I f Application is hereby made to San Joaquin County for a permit to construct and/ori th application is made in coa>yliance with Sass Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. A�,( !Z3 - "F/-Q r Job Address 1576, `001Un2 L'LU t21U ^ City STZX ,TbrJ Lot 81te/Acreage I i2- Arc JJ��,,f� 1 Owner's Name IY40 tCL '�,4AYC U G Z _ Address 1t'o33 W. Phone 464- 1 ! 4 �ry��. _ Conti actofSCECX21Isf_I5kP1.yr7Ar1Qd Address-� C. STbGK'fQ License No..SI - � �.�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or Service Vell ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Vell DISTANCE TO NEAREST: SEPTIC TANK ,&1A SEWER LINES 26 DISPOSAL FLD,.N/�_ PROP. LINE 3. I FOUNDATION -02-L— AGRICULTURE WELL OTHER WELL-1S� PITS/SUMPS A11A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFfCATIONS n Indusuisl ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing p G Specificationsl F_4a �MPublic 1:1 Other ❑ Delta Depth of Grout Seal �r/Z�A -T� .oNi rvr2.�NG :�r� Type of Grout CC-mf'--'r' Imijation —S..LApp(cx. Depth ❑ Eastern 5uria'ce Saul installed by C0A.)' J Repair Work Done U Type of Pump Mi.P. Stare Work Done _ Well Destruction ❑ Wall Diameter Sealing Material 4 Depth f� Depth Piller Material i Depth 1 TYPE OF SEPTIC WORK: NEWINSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION 0 INo septic system permitted it pubfic sewer is Ins'I seavailable within 200 faet,l � ulletion will rve: Residence ` Commercial_ Other Nuritbef of living units; Number of bedrooms Chuacter of soil to a depth of 3 feel: SEPTIC TANKWater table depth ❑ Type/Mfg Capacity-� No. Compartments PKG.iTREATMENT PLT. Q Method of Disposal Distance to nearest: Well Foundation _ Property Line LEACHING LINE f❑ No. 8 Length of lines FILTER BED Total {angth/lira ❑ Distance to nearest: Wel!�_ Foundation .i Property Line r SEEPAGE PITS I I Depth Sire SUMAS Number rq Cl Distance to nearest: Well _ Foundation ! t�.J�� DISPOSAL PONDS Q Property Line I hereby Certify that i have prepared this application ano that the work will be done in sccortla 1994 rules and regulations of the San Joaquin County nce with San Joaquin county ordinances, state laws, and Homeowner or licensed agmt's signature certifies the feaow or: 1 certify that In the performance of the work for whichiding �t s' erriiir as issyra� shall not HO to an �ht� ;..X11 ��• ,.. +� employ Y Person in such manner as to become subjeCr to workmen's compensation laws of California,"Contractor's hi in f!,5 certifies the following:"I cenify that in the performance of the work for which thin permit is issued, l shalt sm to g �rsuta<Car�jr�s`�r,g signature tion laws of Californla." p y persons subject to workman s compensa• The applican Ca all requi d ins ,Ctions. C ampfets drawing on reverse side, Signed Title: Date; DEPARTMENT USE ONLY Application Accepted by II ,! Data Area Pk or Grout Inspection by K Date Additional Comments; 5 Final Inspection by Date Applicant - Rasura all copies to: SAN JOAQf1I1 COUNTY PUBLIC HEALTH SERVICES 44443 N SMNoAQUIN TP DIVISION B009, STUCKTON, CA 95201 FEF AMOUNT DUE AMOUNT REMITTED � € INFO CASH RECEIVED BY E OO DATE PERMIT'ND. I -, !43-74 rAfV.�I��I �� 41 1 :r.yr SII �.