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S� APPLIC ATS,,._ FOR l D:UdiT F � 'fey ,.Y � SAN JOnrfJh RNTX P- LIC HEALTH SE.RVIChS ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, S ETON, CA 95201 (209) 468--3447 REMIX EMIRES I LW PROM DA g Iss= (Complete in Triplicate) Application Is hereby made to San Joaquin County for a }. application is made in C permit na construct sad/or instal] the work herein described. This oltb Sere ces. Sore Joaquin County Ordinance No. SI►9 and 1862 and the Rules and Angulations of San Joaquin County Public Health Services. 2911 Job Address F71 / City rT Lot Size/Acreage Owner's Name G Address 1;7. ri® Phones a2 9 77 Conlracto Address 4EGl/ -7 Y License NaV_�Phon 9� S`f J TYPE OF WELL/PUMP: N WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service, well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Monitors F. / OTHER ❑ Monitoring-.Will 0 DISTANCE TO NEAREST: SEPTIC TANK 1 oS SEWER LINES - DISPOSAL FLD, PROP. LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ~ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial Open Bottom ❑ Manteca Dia, of Well Excav�a 'on tyn. ,o Dia:of Well Casin ��,...........,��`.r.i�d4*•�--.^�Glatrl�.Ear•$,�aox._. � _ �'�"�•,� Spec�f�cations g f7 Other ❑ Delta Depth of Grout Seal _1 oe T ype of Grout .1 M Public'Irrigaon 742QAP6rox._Mpth `_❑ Eastern I Surface Soul Installed by Repair Work Done 0 ._Type of Pump H.P. State Work Dona_ i r`4r Wolf Destruction C] :i_ Well Diameter - :Seals:$ Anterial}i Depth { r- L Depth Puler Ifaterial 4 Depth i.TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIR/ADDITION ❑ DESTRUCTION G !No septic Other— Number - - se _tics stem per m• itted if p ublicsews available within 200 fetInstallation will.serve:- Residence Cammarcial� Other Number tirr r�r Tfi of living units: Number of bedrooms J , Character of 000 to a depth of 3 feet: D Water table depth SEPTICJANK _._ -Type/Mfg — Capacity. No. Compartments , PKG. TREATMENT PLT.0 Method of Disposal L Dlstancerto nearest: Well Foundation Property Line xi I LEACHING LINE JO No. 6 Length of linos i'FILTER BED - Total length/sire i Q: Distance to nearest: Well Foundation — Property Line SEEPAGE.PIT C I Depth Sire Number c SUMPS L't Distance to nearest: Well Foundation Pro ' DISPOSAL PONDS-'t.~p i Property Line t, I hereby-sonify that Lheve prepared this application and that the work will be done in accordance with San Joaquin county ordlnancei,.state la rules and'regulations 6f the San oagteTrt'County ,_ _ _-- _- _. .-. _.__.. ._. _ a F Home owner,or licentad agent's natur"rtifies the following- I cern that in the p _l emplo an ' � certify performance of the work for which this permit is issued, I all Y V Pwson,ii such manner+is 61WKome.-subject to workman's compensation laws of California,"Contractor's hiring o►sub-contracting spne,urs onJWvi of fCiii�orril�a. i that irt the performance of the work for which this p•rmit-is is:usd,_i shall Amploy person4.subjact to,workmrrn'.corr+psnia• The appliu mu call for`all required ' tions. Complete drawing an reverse side. Signed Title: _'70 Date: _ f� FOR DEPARTMENT USE ONLY APPlica;ion Accepted by Date Area Pit or Grout Inspection byj:-.F Data_��_ Final lnspection by_ ;�; y�_ r ;;ata Additional Comments: '' L Applicant - Return all copies to: SAN JOAQUIN CO TY PUBLIC HEALTH SERVICES l ENVIRONMENTAL HEALTH DIVISION lMWIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUAMOUNT AEMITTED FEE- INFO NT DUE CKRECEIVEDRECEIVED 8V DATE P6AM1T'NO, . EN 13.21 IREV.iinsi �q.4� Q C� I `/�I�� 4F ! EH�t.71 '.. I�-3i- G IG -3�cp,' . 1