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t � � APPLICATION FOR PERMIT �V-A SAN JOAQUIN COUNTY PUBLIC HEALTH SVI t + ENVIRONUMITAL HEALTH DIVISION RR 445 N SAN JOAQUiN P 0 BOX 2009, STOCKTON CA 9520 FAC REMIT ES YEAR ER (Compete in Triplicate) � # Application Is hereby awAe,to San Joaquin County for a permit to construct and/or install the work herein described, This Application is made in oomp2lance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulatlona of Ban Joaquin Couaty Public Health Services. Job AddressIM47A( l/WL/ Q ` ,9 Ae&A";UP City_t. fir[t - _Q +��/y Lot 511 u/Acreage Owner's Name Address .-1 •U fflax gaeft ._ a Phone "c? Contractor ri4L.lA1i MEl�dress 361V S . ase N1ftz6E_Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT f7 DESTRUCTION�WL.Dut of Service Hell O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ©Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack Q Tracy Type of Casing_ Specifications - 1.1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —ApproN. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Do Well Destruction bZ Waft Diameter Sealing Material i Depth � O ^" S d C Depth.fes Hiller Material i Depth /00 SdA149 TYPE OF SEPTIC WORK: 'NEW INSTALLATION I I REPAIA/ADDfTION I I DESTRUCTION l I INo septic system permitted it public sewer is Installation will serve; Rasidertt:a,___. Commercial.` Other available within.2W feet.I Number of living units: Number of bedrooms i Chsractar of sap to a depth of 3 feet: -•—water t SEPTIC TANK ❑ Type/Mfg Capacity No.Coma PKG.TREATMENT PLT.❑ F Method Distance to nearest: Well Foundation Property Line eett LEACHING UNE Cl No. 8 Length of lines Total langth/size SAN JOAqUINCOUNT FILTER BED C1 Distance to nearest: Well Foundation pro p° j� N1AtHEAI.TH DIVISION SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Wall Foundation_ property 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, state is rules and regulations of the San Joaquin County ws, end Home owner or licensed agent's signature cenifies the following: "I certify that In the performance of the work for which this Perron is issued, I shell not employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting ttigrlsture earfifies the following:"i certify that in the performance o!the work ler which this permit is issued, I shall tion taws of California." employ y persons o work m componse- The spplfcan t SVI ffir ap requAod in 111006. Complete drawing oneras 91 10. - �' �(�f/ Signed Title:7- I FOR DEPARTMENT USE ONLY ' Application Accepted by — .r _ � Dale Pit or Grout Inspection by Date Final Inspection by Date orf Additional Commonts: F. * / Applicant - Return all copies to: Ban Joaquin County b is Hea h Sery es 448Environmental anJoa Health Permit2009, Stk A1C) V__1In �f j�,�,,�� i4s a Ban Joaquin, P 0 Box x009, 9tka. QA 95201 IGr '+fXY t.� ��"" -3 i 9 cto FEE AMOUNT Ot1E AhAOUNT RE11tITTEO 'No. LC b INFO K H RECEIVES 9Y PATE PERMIT'No. • EN 14-24 IREV.t r R 61 EM SI•Ie