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APPLD-Al ION T SAN JOAQUIN COUNTY PUBLIC 11EALI'ii SEitVICLS I,NV I IIONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN , PHONE (209 )468- 3420 P O BOX 2009 , STOCKTON , CA 3520.E PERM T'1 LXp T RES T YEAR PROM DA`1'I) f SSULD (C'nttiplete in 'illpllcat �) Application in hereby made to San Joaquin County Cor a permit to construct and/or install the work hercln described Thie appllca;iort Is made in eattpllance with San Joaqufn County Ordinance No 119 and 1862 and the Hulcs and Regulatlona of Sdn Joaquin County Public Health Services I C 1-{ Job Address _� +. +L/ t-- '51( ZZ l -- - --- City _✓ �lr-4tr.'� LJI � �-------_----- -- i� l /� Phonu Owner s Name t e 6 ri r-E"I_lf _ ---- J License Na al L+ L Phone i C 'i 1� 1l � Contractor - - TYPE—OF WELL/PUMP NEW WELL C7 WELL REPCM,11MENT F-1 DESTRUCTION fI Out of Service Well C1 PUft4P INSTALLATION (7 SYSTEM REPAIR [ i OTHER Ci Monitoring cell (� DISTANCE TO NEAREST SEPTIC TANK _ SEWER LINES -- _ DISPOSAL FLO _ PROP LINE — —� FOUNDATION - __ AGRICULTURE WELL T- OTHER WELL PITnS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS SQA PL4 f `t -a,. ► `Y'� {) Industrial 13uttom [hManluca Dia of Well Excavation— _ _ — _ Dia of well Casutg Specifications[ I O0;Tte5ltC/PrIVdIC [ t Gravel Pack ! 1 Tracy Type of Casirny I i Public 1401hur S„tl b try I I Ouhd Depth o1 C}+nul tidalType of Grout I f lrr+ijat+on ___ Approu Depth) I I Edstdnt Sundae Seal Insidlled by P e o1 Pum Sla a W rk Re au Work Done I� Type P H P - � i Sealing Material A Depth _ a►" �` Well Destruction 0 Wall Diameter)-L _ �ti l pepth�L p��)'M— Filler Haterlal L Depth 1 TYPE QF SEPTIC WORK NEW INSTAI LAIJON I I REPAIRIADD1TIOf+I I I DESTRUCTION 1I (No obn septic system instilled If public sdwef Is aViLtld ithin f Installation wrli serve Reslddnca r Commercial —_ Uther _- 1 Number of living units Number of bedrooms -_ Character of sod to a dapllt of I 'eat Water table depth SEPTIC TANK 0 Type/Mfg Capacity_ __ No Compartments PKG TREATMENT PLT 0 Method of Disposal f Dtstanca to nearest well _ Foundation --- Property Llns r LEACHING LINE L1 No b Length of lines — _ - Total length/size FILTER—BED i 1 Or,tari uta neerett Well -_ Four+aauon Property Line _ SEEPAGE PLUS I I Depth — Size _- -__ _ Number - SUMPS I I Disldnce to nearest Well Foundation _ _ _ Property Line r DISPOSAL PONDS (l I hereby Cattily 1641. 1 he\.e hrepdfad this appllcauon and that the work will lJu dune in dl.iUrddIIr d will) San Joaquin county ordinances stale laws ants rules and regulations of the San Joaquin County Home owner or licensed agent s signalute carttftes the followutg I certify 0141 tit the 10+turm4ntce of ilia work for which this permit is msuod I shall not employ any person in such mannar as to become subtect to workman s compensation laws of California Contractor s hiring or sub conlrecung s+gnaluw certifies the following I certify that In the performance of the work for which this permit is ucued I shalt employ persona subject to workman s COmponsd lion laws of California 1 he uphhcant lust call for all required uu pections Complete drawing on ruvurse side Signed x_ - _ - Tltie —Pr 1__ �:Li v� ! - Date Jf LOR DEPARTMENT USE ONLI _ %) �Y.1 � / 1�1i� Gale �y Apphu capn Accepted by Area --- Pit or Grout Insptiction by Date -_ Final Intpaction by __ _ _ Date _ Additional Conin-mms -__ - - ----- - ` Aplsl I. tilt - lit't t+r et III t u1'Le_5 to San tou4ttl n Cuunty 1111hl it Ileal t h 't +vii t E;nvitonatrnta1 11cnIth 1'trnrIL/itrvttr. 44 N Sun 10tigUin 1' U Htrn 2009 Stkn ( A 'JJ1U1 F0 4T— AIOUNT DUE AMOUNT REAMIT7 ED CK RECEIVED BY GATE PERMJT NOl 7 INCASti _ - Pully' I 1 N t1.24 uuv �s+