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p APPLICATION FOR PERMIT SAH JOAQUrN COUNTY PUBLIC REAL TFI SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 ii ` (COlttplete In Triplicate) Appllcetlon is hereby ssCoto to gap Jcoqwith San County for a permit to construct and/or install the work°herein described. This os.quiatloa is mage in eLlth Sera with Baa Joaquin County Ordinance No. 549 and 1862 and the Rules+and Regulations of San Joaqula-County Rrb11e Health Services. � � i " ppn5 (43 -•' Z.Cao-o,5_a r I: Job Address ROAD City 7 Lot 51se/Acre (',q,�7-� age J Ip, Qwner's Name Address Phone f`.-Z Lo q � ! Conlraclor5i�% , u = LQR Address r ,. __6.7J 7 License No: ' ZCoB phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION,O Out or Sarvlce Well Cl .PUMP INSTALL4TIOW-0 jih �... _, SYSTEM REPAIR,0 �--�r _ ' OTHER Q," 3 Monitoring uell5 � DISTANCE TO NEAREST. SEPTIC TANK 2d- ��SEWER LINES �I . LINE FOUNDATION ?�' IhAGRICULTURE WEL��//fl OTHER DISPSWELL�" P SPSUMPS INTENDED USE TYPE OF WELL. PR09LEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 'r Domestic/Private :R Dia. of Well Casing 4 _-- Gravel Pack O Tracy Type of Casin g� � O J� Specifications.:��, d Public 1:1 Other Depth of Grout 59x1 �vt�rliCh ❑ Daha Typo of Grout C� CJ Irrigation i�Approx. Depth ❑ Eastern Surface Saal Installed by CPA ;x12.4 c7r�� Repair Work Done D T p II YPe of Pump I H.P. Scala Work Dans � '• r'�' Wall Destruction ❑ Well Diameter Beetling Material A Depth v Depth �� Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION L1 DESTRUCTION ® (No septic system permitted if public sewer is : Intl offs lion will serve: Residence _ Cavailable within 200 feet,) ommerciaE I other Number of living units: Number of bedrooms !� Character of soil to a depth of 3 Joel: SEPTIC TANK Water table depth ❑ Type/Mfg IN PKG. TREATMENT PLT. Q Capacity_ No. Compartments Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines f Total length/sirs FILTER BED n Distance to nearest: We If Foundation 'Properly Line SEEPAGE PITS 1 1 Depth, Sira - - �_ -F '.Number ..--.. „-, _�,.. -._ .- . -z-T x SUMPS LI Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS 0 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 San Joaquin County ij Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which chi, permit is issued, Ishall not w employ any person in such manner as to become subject [o, ortman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work lot which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of.,Californla." Ir The spplicari�l�m1u ca r rall ir"ulfop inspections. Complete drawing on reverse side. Signed Title: ��/' Dal/994— iF DEPARTMENT USE ONLY Application Accepted by } Dale Area Pit or Grout Inspection by /�/'C Dan6e �� Final Inspection by I Date Additional Comments; S e I Applicant - Return ell eopiea to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESLJ�/g ENVIRONWENTAL'IHEALTH DIVISION PERMIT/SERVICES � -Alp?�J .rn• 44$ N SAH JOAQUIN, P O BOX 2009, STOCKTON• CA 95201: FEE INFO AMOVNY DUE AMOUNT REAiTTED K RECEIVED HY CASH DATE PERMIT'NO. .. .." Eh 13.T IREV.r/nsr �� -� j •�j .. £H :4-2d