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L APPLICATION FOR PERMITr SAN�QUIN COUNTY PUBLIC VICES ENVIRONMENTAL HEALTH D VI 445 N SAN JOAQUIN, PHONE (2 9 ,4,f8-3420 P 0 BOX 2009, STOCKTON, T PERMIT =T S FR M (Complete in Triplic te)_ # r a Application is hereby msde.to San Joaquin County for a permit to construct aa/1MH�r�r�sll / is application is made in costPllance with Sm Joaquin County Ordinance Ho. 549 the Rules.sad ReguLtiops of-San Joaquin County Public Health Services. Job Address 1n s1242 A- ,t/gpt_A, ) M4>5 City 7Y, QYy/019MP Lot Size/Acreage �¢,QES Owner's Name «far)t TrZ- (t(2tZC;{Zrrn'A l Address Rn 2nog 1,5-7 S NUm,JTcA '/ one(/ - (9/\a) /B Contractor /1-. '>-F- Y1 X 7 / i/.. ..oi Address's License No +�y� [Q�Phoneamwp TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑i SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES > DISPOSAL FLO'�L PROP. LINE )LC= FOUNDATION S/La' AGRICULTURE WELL / OTHER WELL-.� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Industrial 0 Open Bottom ❑ Manteca Dia. of Wall Excavation al " Dia. of Well Casing n Domestic/Private 1�YGravel Pack Tracy Type or Casing .cv VO 9df Specilptions ftp CV�-5CZ4 ) Il Public n other n Delta Depth of Grout Seal / / Type of Grout,1t7rl� I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by.j��a! Q Repair Work Dona L7 Type of Pump H.P. State Work Done Weil Destruction O Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I 'REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 fest.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms ccc��iG Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Corripartrmnts PKG. TREATMENT PLT.❑ - Method of Disposal D' to nearest: Wall Foundation Property Lina Q LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distancs to nearest: �J Fpur�ation Property Lim SEEPAGE PITS 11 Depth Sire N T'� Number SUMPS LI Distance to nearest: Lim DISPOSAL vndaticn Property Li DISPOSAL PONDS ❑ J /y, 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 ruins and regulations of the San Joaquin County Hone owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ my parson 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 cattily that in the performance of the work for which this permit is issued,I shall employ p by parsons wbjarx to workman's compensa- tion laws of California." , The applicant mwt ,cep y�.ap r red�peetions. Complete drawing on rwerss side. Signed Tids:5;2)f2P Date: 9-AY-S3 FOR DEPARTMENT USE ONLY Application Accepted by 4� f Date n p Ares ' M�t� Ph or Grout Inspection r paction DY Date Final Inspection b Dan 7 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �JL O / -CO JO Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FIts NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 1114 IaEV.treat 7 //� �7 /�/7 / �A' " "/4 9/ f-3 EN 14.2 (1 6