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( APPLICATION FOR PERMIi�' V'. p 9qe� SAN JOAN RONMENTAL HEALTH DN COUNTY PUBLIC IVISION LTH VICES ge� ,I 1601 E. HAZELTON AVE. , PHONE (209)468-3420 M�Y P O BOX 2009, STOC%TON, CA 95201 PN PUQ�N✓)q Z 0 d i HERMIT EXPIRES 1 %EAR FROM DATE ISSUED V/RO�Mfyf4UT�CO[)'' r (Complete In Triplicate) rA4HA«RV�E Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein des crl ed. pplication is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Pu H�a/�,th{,�.�ej�.v 1�f r�/- cit ck f Job Address t Y� I MC 1 ,C� ----r Y Lot Size/Acreage Owner's Name > L1.� Address Q ,t' \' Phone 66-40I Contractor I rQ�� Address3�J5 ��FCSS VI7;�. 'VeNo. Lot. TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT ❑ Licens DESTRUCTION JXO- Pofn Service VY- NEWWell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER '�_' .Mwi LSLlfgWl1l ❑ SEWER LINES DISPOSAL FLO. FOUNDATION AGRICULTURE WELL OTHER WELL PROP. LINE __ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3d � ❑ /Industrial O Open Bottom O Manteca tion � r "Q�rr 19k) rim OVC ❑ Domestic/Private . Dia. of Well ExcavaDia. of Well Casing ❑ Gravel Pack ❑ Tracy Type of Casing 1:1 Other _ Specifications ther fl Delta Depth of Grout Seal 7.© Irrigation —.Approx. Depth I I Eastern TeQype of Grout_—6 i Repair Work Done IJ Type of Pump Surface Seal Installed by H.P. Well Destruction ❑ Well Diameter Sealing Material 6 Depth State Work Done_ Depth Filler Material.& Depth G 40, - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet,) _ Number of living units: __ Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK. ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments Distance to nearest: Well Method of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ 'Distance to nearest: Well Total length/size �. Foundation Property Line SEEPAGE PITS I I Depth SUMPSSize CI Distance to nearest: Weg —�— Number DISPOSAL PONDS ❑ Foundation Property Line I hereby certify that I have prepared nJo this application and that the work will be done in accortlance 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 employ any parson In such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature Performance of the work for which this permit is issued, I shall not certifies the following: "I csnif that in the Performance of the work for which this permit is issued, I shall em to tion laws of Californ' y D y Persons subject to workman's campensa- The applicant mus a for all required inspections. Complete drawing on reverse side. Signed X p qq Title: _rfdri/iYl Data: FOR DEPARTMENT USE ONLY ! Application Accepted by ' / ! Pit or Grout Ins Date 6 Area Inspection by Date - Final Inspection by Additional Comments: Date. Applicant - Return 911 copies to: San Sosquln County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 1 FEE AMOUNT DUE INFO AMOUNT R! 1 1 E0 CA R y CA� VED BY DAr EH t1-24llt V.vn ai �' O TE PERMIT NO. IEH A-M