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,n, - APPLICATION FOR PERMIT ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PE_RvIT EXPIRES T YEAR FROM DATE ISSUE (Complete 1❑ Triplicate) Application IS hereby made to San Joaquin County for a Permit to construct and/or install the work herein described. This application is wade In complimce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,lob Address Sy W ' C747L /27- /g City IDU 1 Lot Site/Acreage tS/1fe Owner'sName f-�/.la lt_ 4Lgr-c Address Rat 2§/ 7 h Gw 1'2n Phone e5f4d Contractor I rwlL F}tp� r,PY!�•*' Address License No. d97d0 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FIDESTRUCTION 0 out of Service Well Cl PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER Cr,)s Mpn,to'ing Mell 0 Pr "o DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l� f ( trial ❑ Open Bottom 0 Manteca Ole. of Well Ezcavanon Dia. of Well Casing omestic/Private 0 Gravel Pack 0 Tracy Type of CasingSpecifications f� M public 1-1 Other ❑ Delta Depth of Grout Seal Typa of Grout U 1 Cl I...Italian __ Approx. Depth 0 Eastern Sumacs Seal Installed by �n� P l Repair Work Dons ❑ Type of Pump H.P. Stave Work Done _ Well Destruction ��Wnll Diameter. Sealing Material a Depth y G-e T Z`O Depth -SOF Piller Material a Depth 1 TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION G INo seplic system permitted if public sewer is available within 200 1eet.1 Installation will serve: Residence _ Commercial_ Other Number of Whit units: _ Number of bedrooms Character of soil to a depth of 3 lose Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. a Length of lines Total length/size FILTER SED 0 Distance to nearest: Well Foundation - Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancas, state Is end /- rules Intl regulations of the San Joaquin County1 1 Home owner or licensed agent's signature certifies the following: "I comity.that In the pemormance of the work for which this permit is issued. I shall not employ any person in such manner as to become sublect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "1 qpnity that in the performance of the work for which this permit ie issued, I shell employ persons subject to workman's compenu tlon laws of Celil The applic must f r uired inspections. Complete drawing on reverse side. Signed �j - Title: _a' cUD-.^-T' Date: � FO DEPARTMENT USE ONLY ? /� Application Accepted by Date �.�-��-`��-�/ Area q Pit or Grout Inspection by DD,a,,ta�i / F�ina/l�InaDection by Date Additional Comments: I/ a""'w"'`' izO 990'0c. ""� - Applicmt - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 FEE AMOUNT OtIE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO INEO . fal,;riMEv „�,� RR.�D ��Ss Sm MR -�Y4/ i-insz fel'I ai J