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CA -y�A4 APPL I CA,TI ON FOR PERM I T sq� +fid SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �y gr, y&�,� ENV I RONIMTAL HEALTH DIVISION A)?V 5 Co I 445PNOSAN BO%J2009 NSTOCSTON(2CA)952Q142Q ReCie/Ve SAY �® SA f 3 f l6 I PERM T 1R IRES Y FROM D TE 5U PU tvjo 1 9�3 (Complete in Triplicate} IENVIp��CH�q�r CCUNr r - ��_ NM�NTAL H&gLT1�RVICcS Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. /*RV/S1 application In made in cee�liance:with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Q� Joaquitl Counter Fub]ic Heriilth�8ervices. Job Addresi,r Y Y Ct (, 4i 9V Z60--1f5-0—a4 City ,( Lot Size/Acreage Owner's Name Lnt ' Q Address !"Zr1 Phone Ads- Contractor 3d '-Contractor j&AJ2 Address_ e7��/ kGil�d° d License No.-210143_Phone TYPE OF WELL/PUMP: f NEW WELL O WELL REPLACEMENT DESTRUCTION Rf Out of Service Well ❑ PUMP INSTALLATION p SYSTEM REPAIR 0 OTHER O Monitoring Well 0 � r � DISTANCE TO NEAREST: SEPTIC TANK • _ SEWER LINES DISPOSAL FLO.�� PROP. LINE s � ry FOUNDATION AGRICULTURE WELL OTHER WELL—L2,4Zf PITS/SUMPS INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 industrial ❑ Open Bottom ❑ Manteca Dia. of well Excavation— �ZQ' ia. of Weil Casing Domestic/Private Gravel Pack Tracy Type of Casing_ 4pecifications—. /Gb ' I'1 Public f-1 Ofiler I-1 Delta Depth of Grout Seal Type of Grout I i Irrigation e Appros. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. Stats Work Done _ Well Destruction x Weil Diameter _ Sealing Material & Depth r _ Depth:� ? Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I 'REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is 1. available within 200 feel.) i Installation will serve: Reside Ire— Commercial_ Other Number of living units: Number of bedrooms a Character of&A to a depth of 3 fast,, Water table depth SEPTIC TANK. i ❑ Type/M!g Capacity No. Compartments PKG. TREATMENT PLT.❑ ' r II! Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No I�& Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line .II. SEEPAGE: PITS I I f Depth Sire Number SUMPS LI Dist nee to nearest: Weil Foundation Property Line =DISPOSAL PONDS ,❑ IG _ 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 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not ; employ any person in such mannerlas to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:'"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant m st call for aft rsquCrad in tions. Complete drawing o e rse side. Signed J C! Tule whuDate• �O2'�� �I DEPAR NT Application Accepted by USE ONLY Dates Area - Grout Inspection by/ ,A�Fiinal In by Data � g /i�� � Additional Comments:�` C � �'! ] r �l /P y✓ i Applicant - Return all Ohhhhopies to: San Joaquin County Public Health Services Environmental Health Permit/Services r 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT 6UE AMOUNT INFO 1 a REMITTED HCK RECEIVED By OATE PERMIT'NO.