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APPLICATION• FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTHeha.VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 SOS 2009, STOCITON, CA 95201 <br /> �.... PERMIT ESPIRES 1 YEAR FROM DA Tfi ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein descrihed. his <br /> application is made in compliance vlth San Joaquin County Ordinance do. 549 and 1862 and the Rules and Regulatlons of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> 54CC EQS+ City L001 Lot Site/Acreage = I ! O <br /> D — <br /> Owner s Name CO for Spot. I r1C. Adorers 5400 Ea {' 4a+ La,nt Phone(7-01) 3-:53-0Z-3 <br /> Vj „// 91691 <br /> Con«actorF�TC-/� Address F.O. 1 til. 1644 W. S-A�CA,icenseNo. 55ZIQF- Phone(916 373- III <br /> i TYPE OF WELL/PUMP: NEW WELL 5r WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Veli5 <br /> DISTANCE TO NEAREST: SEPTIC TANK 2oa +. SEWER LINES -1 / DISPOSAL FLO. AJIA PROP. LINE Lag-F4. <br /> FOUNDATION ZOO 4'-t- AGRICULTURE WELL 15504.OTHER WELL b:� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- too <br /> Industrial ❑ Open Bonom ❑ Manteca Dia. of We” Excavation t e) Dia. of Well Casing <br /> 4 " 51.1.. +0 PVC- <br /> "1 Domestic/Private KG(a%,* Pack ❑ Tracy Tree of Casing Specifications Gro <br /> I �'1 Puol.c !7 Otter fl Delis Oepm of Grout Seal 38-�'f - 5..•�..-a Type of Grout <br /> I I Inn)ation _A00rox. Depth r/I�I Eastern SuA a Soul installed by <br /> Reosa Wort Done LD Type of Pump 1 H.P. State W_ dict Done _ <br /> fr Sea11:.g M i rial Depth -55 4 - (S+�{-•k/ (�4n. . <br /> i Well Destruction C3 Well Diameter , U <br /> -I I Depth 60 t�. filler la►urial i Depth �rr+-�e Pr--e <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/AOOITION I 1 DESTRUCTION I I INP septic system permitted of oublrc sewer rot <br /> available within 200 feet.) <br /> jInstallation vel e: Residence Commercial— Other <br /> `�. Numper of Irving units; Number of ttedrooms <br /> Character of sod to a osotn of 3 W a le death <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartrtrnn <br /> PKG. TREATMENT PLT.❑ Msthod of Disposal <br /> Distance to nearest: Well Found Property Line <br /> I <br /> i <br /> LEACHING LINE ❑ No. b Length of lines Total lengtri/size <br /> FILTER BED ❑ Distance t rest: Well Foundation Property Line <br /> JSEEPAGE PITS I Depth Sire Number <br /> SUMPS LI Distance to nearest: Walt Foundation Property Line <br /> OISP L PONOS !7 <br /> I hereby Certify that I have prepared this application and that inn wort will be done in accordance with San Joaquin county ordinances. state laws. and <br /> rules ano regulations of the San Joaouin County <br /> Home owner or licensed agent's signature certifies the following: ­I comfy that in the performance of trio work for which this permit is issued. I snap not <br /> emoloy any person m such manner as to become aubteet to workmen's compensation laws of CaGfornrs."Contractor's noting or suo-contracting signature <br /> canities trio following• "I candy that In trio performance of trio work for wnrch this permit Is Issued.I snag employ Persons sublect to woraman'a COrnoensa• <br /> i non laws of California." , _ ,/ <br /> The applicant mt�sUdl/lO�af6�Q.UWOT msp"Ilk'nf��Olh�la/a drawing on reverse sloe. <br /> Signed X Cr.. / �.yi' ,'�i.l/ 'IL%nr.�// ':iCTitle: _ .:/ Date: <br /> / FOR DEPARTMENT USE ONLY <br /> Aoolicanon Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Sao Joaquin County Public Health <br /> Services, E vlronmental Health Pe.-mit/Services <br /> 1601 E. Haseiton Ave., ? 0 Boz 2009. Stockton. CA 95201 <br /> FEE AMOUNT DUE AMC <br /> AMOUNT REMITTEO CKSHs RECEIVED BY DATE l ERMIT No. <br /> INfO A <br /> '. EN 13-14 IaN.Ir-L <br /> • f"'r•a1 <br />