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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 x. HAZELTON AVE. , PHONE (209)468^3420 P O BOX 2009, STOCKTON, CA 95201 C PMIT EXPIRES 1 YEAR FROM DATE ISSM i (Complete in Triplicate) "AIS00)-110 _ QL7 Application is hereby, made,to San Joaquin County for a permit to construct and/or install the Vork herein described. This application is made in Compliance frith San Joaquin County Or nonce No. 54 and 1862 and the Rules a.nd Regulations of San Joaquin County Public Health Services. /6 Joh Address / �^ City RY r Edt S /A Y Ae"W— co Address F't!t='fes� one ry Pr' N me _ k! Yd5_TK-R-c4. IA-�vsTR-, c�tz..LrH. art . I y Contractor.P-XC-(=,-- r7=C---f AddressL/t-?yC'y' I2T!. F1'4—e4AJ'License N3o� �rt15 Phar& 5�0- y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Wall E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE S D e FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 13 0a'7r t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS HA Y' ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia, of Well Casing Yo J EI Domestic/Private ❑ Gravel Pack Rl Tracy Type of Casing Specifications I'1 Public I') Other fl Delta Depth of Grout Seat Type of Grout + i Irrigation —.Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done A<AL fi/ti Well Destruction O Wall Diameter Sealing Material 8 Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION 111No septic system permitted it public sewer is available within 200 faaO Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms ....9 Character of son to a depth of 3 feet: Water"sable depth Q SEPTIC TANK.. 0 TypelMfg Capacity No. Compartments CD PKG. TREATMENT PLT.© Method o1 Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of linea Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Sire Number SUMPS 1.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawJanrules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I sh employ any peteon in such manner as to become subject to workman's compensation laws of California,"Contractors hiring or sub-contracting signature certifies the following:"1 certify that in the performance of The work for which this permit is issued, I stall employ persons subject to workmen's cwmpensa- tion lays of California." The applicant must call-fd inspections. Complete drawing on reverse side. / Signed 7t` __._..� Title: S�i�/012 r7e'c.v Date' &-A-M R DEPAIR71ENY USE ONLY Applicatio Accepted by Date Aron Pit or Grout Inspection by Date Final Inspection by Date 6 s Additional Comments: " Applicant - Return all copies to: San Joaquin County Public Health Services, Enviroumental Health Permit/Services 1601 E. Hatelton Ave y, P 0 x 2009. Stockton, CA 85201 FEE`f INFO AMOUNT OUE AMOUpNTT�REMITTED + CK 11 ER RECEIVED BY DATE PMIT"ef0. . EH 14.71 MCV.r/nal56 99 1:1a- J y i S��-� CH 31.20 — ! , F 1