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APPLICATION YOR PERMIT SAN JOAQUIN ('OUNTY PUBLIC HEALTH SERVICES RNVIH0NHENTAL HEALTH DIVISION 1601 E. HA'LELTON AVE.. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 �1B�I�T FXPIHFS 1 YrjAR FROM DATE ISSUED (Complete in Triplicate) Application is herehy made•W San Joaquin County for a permit to construct and/or install the vork herein described. This appllcstino is rads in cosVliance vitt Dan Joaquin Cm ty Ordinance No. 549 and :862 and the Rules sad Regulations of San Joaquin County Public Health Services. (' , n �. . S4/Acreage c Job Address �� _� City tom, Lot is&/Areage Owner'*Name -'"Y � ��'�� Add,ass Phone S Contracts a a` - f-L11 ,nee No f on ~ TYPE OF WELL/PV NEW WELL WELL PEPLACEMENT rl DESTRUCTION ❑Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR C! OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO.�_ PROP. LIME rF FOUNDATION _ AGRICULTURE WELL OTHER WELL_- PITS/SUMPS _ I NCF.D USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v L C)Industria ❑Open Bottom ❑Manteca Dia.of Well Excavation_ Du. of I'el aging r 1 Domestic/Prlvat O Gravel Pack ❑Tracy Type of Casing Specd twos V/ 'J , I'I Publk Other rl Delta Depth o!Grout Seal _ T of Grout 4 I I Irrigation _ os. Depth I I '.astarr. Surface Saul Instailad by R Repsi:Work Data U Typo of Pu.f. _ H.P. State Work D ?� Wall Destruction ❑ Well Diameter�_� Sealing Material • De,th Depth Filler Nate-lel A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I EPAIR/ADDITION I I DESTRUCT m N INo septic cysiepermittvd rf publit:wvver is S / available within 200 fest.) / Instalkrkn will serve: Pesidence__ Com,"w" l Mer / Num.'w of Ging units:__ Number of bedrooms Chuactsr a'wif to a depth of 3 feet Water table depth, SEPTIC TANK ❑ Type/Mfg Capacity No.Compartrrtants PKQ.TREATMENT PLT.C1 Method of D*wsal Distance to nvsrest,�- Well F;unaation Property Line LEACHING UNE D No.6 Lertgth of linos is, aQthmsire FILTER BED c) Dl�to nearost: Well FoundationPr0 Line S11PAGE FITS j I I Death _Sire _. Number _ SUTA:S �'� 1.1 Distance to nearest: Well Foundation Property Line p15?OSA_ PONDS ❑ i I hargtfy tortity,that 1 have prepared rhis application and that the work will be done in accordance with San Joaquin county rdinanees,stats laws,and rulei and regulations of the Son Joaquin County 1 Home ovr:.,jr x Ikcrised agan."s signature cerifies the Wowing:"I certify that in the performance of the work for which this p rmit is issued.1 shall not employ any wson In such manner as to become subject to workmen's compensation laws of California."Centractoes hiring or 1ub•contractinq signature { cmviss the Wowing:"I csrnity abet in the psrformerua of ins work for which this permit is iiisued,I shalt employ persons subject to workman's eompsnss• r Yfn laws of California." i 'Tic;c9pboant r _ oil tions.convAsts drawing st reveres side. k J m rn'�i� Sigrint Y' (�(� �` 6f Title: _ Duo: 4 ( i • -71 L FQA_DEPARTMENT USE ONLY AoMIcal'on Accepted by J _ Date Ph or Grtwt Inspection by _ Dote Final Inspection by Date Additionai Comment$: -- ADplitaa,'i - Return all copies tot San Joaquiu County T%blic Health Services. Alylronnentatl Health Pertait/Se:•vices 1601 I. Saselton Ave.. P O 7Box 200009, Stockton. CA 95201 p� FEE AMCM1iNT OtiE AMOUNT REMITTED CCK ASI'r I REC'.IVED By GATE PERMIT'NO INFO IVS E t �1 t"F• • tN tlM tall.raasr / �� Mr 1 r r i ad �� 1 S o a. xl �,. ipr. .'(�ilsY��.T/%.•�)f 9•Ftr.�41��#��'tt.:i..�:�lYawWtS�rtaA W]MtCGMYV.MTTCE41 1af41Y16•L-,aLiI6WH�`t.4...W.1.4WI�K"•..��'•��!q.a�y �rm a `fit tf<`r.