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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PEMIT UEIRES 1 YEAR I+ROM DATfi ISSUED (Complete iD Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application to made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ? EQ 7 !I// () (�✓ City!`k+1 Lot Size/Acreage F b Address ��"--lf- c� (� y�� L wner's Name A C ��rP,n h IA Address g" tyq _-/�=n,`D V /7 V Phone O 6. ontractor Address License No. Phone `TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOW❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D FLD. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS f, ❑ Industrial ❑ Open Som om ❑ eca Dia. of Wall Excavation Dia. of Well Casing 'IIIY V• U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Vv M Public 171 Olfte ❑ Delta Depth of Grout Seal Type of Grout — M Irrigation _.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. Slats Work Done Well Dast ' n ❑ Well Diameter Sealing Material i Depth V Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION G INo septic system permitted it public sewer is available within 200 feii Installation will serve: Residence-\C.. Commercial_ Other Number of living units: 4— Number of bedrooms Character of &oil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 7!�!,irdation ✓✓Cpacity Do NCmartments Z- PKG. TREATMENT PLT. ❑ L,,., /, Method of Disposal PDistance to nearest: Well Property Line 2V i. LEACHING LINE No. g Length of lines Total length/size �� FILTER BED ❑ Distance t0 nearest: Well /Sr7f Foundation �� Property Line SEEPAGE PITS 11 Depth I Sire �X �a Number z — 0 U SUMPS ):4 Distance to nearest: Well Founa 7- Property Lina DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done 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 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 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 California." The applicant ust call for al required inspection Complete drawing on reverse side. Signe t/ �'�' Title: OLAY1?l!/li Date: i/ ` R APARTMENT USE ONLY __ -- _ — Applicstlo Accoptodeby i1fz. �A, - Date a Pit or Grout Inspection by Date Final Inspection by Da[s� Additlonal Comments: Applicant - Return all Copies to[ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASKH RECEIVED BY DATE PERMIT'NO. INFO C ` EN 11.11IAEV.i,xal roe //V,00 �-.13 9-13-9 r� qv-ay6 EH'.a.M