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J~ APPLICATION FOR PERMI' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 'COP 1601 E. HAVE. , PHONE (209)468-3420 BOX 200 P O BOR 2009, STOC%TON, CA 95201 )Uj PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 cevspliance vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,/ Job Address 77,�D 25g5Fnr �AJV 'Y� Cit Lot Size/Acreage Owner's Name r / dmp t_Ijyzh Address /� ,, L - '`' ,, Phonev_foll— S Cont,actori_�114E&&fnr _KL.il,[[iAddress/%�aw 99�/. 4((�6k,�t,� License Phone /16-6"- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl PUMP INSTAINSTALLATION111SVSTE REPAIR ❑ OTHER ❑ Monitoring Well x/ DISTANCE TO NEAREST: SEPTIC TANK` &2LQ SEWER LINES 4/,# DISPOSAL FLD.NA PROP. LINE DOOM Y" FOUNDATION =4&_ AGRICULTURE WELL._ OTHER WELL PITS/SUMPS XR-0, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '/i2 I-I Industrial E) Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing 4r SC Domestic/Private (Gravel Pack ❑ Tracy Type of Casing Eye— Specifications I I Public I I Other fl Delta Depth of Grout Seal A:Z Type of Grot N I i Irrigation __ Approx. Depth I I Eastern Surface Seal Installed byi /.C�.�il Repair Work Dom ❑ Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material a Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 Ieet.f Installation will servo: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms_ Character of Will to a depth of 3 feet _ .__ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Q PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. A Length of lines Total length/size ViNi1 FILTER RED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest; Well 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 laws, and rules and regulations of the Sen 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 nah- employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cerE ifiing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tioornia." Thc II in requir d inspections. Complete drawing reverse side. Title(-ORPARTMENT USE ONLIAOApted by Date L 2C p AraePn ction by ' Date� Final Inspection by__2. SS)7Y\ Date Additional Comments: _!;;��1 / A[ 617 a�f V.3 1 S l I i — Applicant - Return all copies tot Ban Joaquin County Public Health Services, Environmental Health Peralt/Seriioes 14601 E. Razelton Ave., P x 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT CK CK H RECEIVED 9y DATE �` PERMIT NO. q . [., 24(REV.r/e!) 7—�fJAT /40 1?0- 601 „ ,�