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Y: APPLICATION FOR PERI!I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERItICES t ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2069;' $TOCHTON, CA 95201 ' (209) 468-3447 PERMIT EXPIRES 1 YEAR ,rRgX DATE ISSUED (Complete in. Triplicate) Application Is hereby raade,to San Joaquin County for a permit to construct and/or inatall the work herein described. This application ie made In Compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County f s w,t e.Y CeaiJ1/'/s �raLSf l�/Q-1 d Q l / (�Job Address h L1/ rc �1/31-Id0-o 1i,8 city Lot.Sit a/Acreage [ I / , r Owner's Name 1E .S `�'�L✓,d✓G�o�} IJ ` .S�+J��R�!SCD r C'A �f0,5' N Address � KIST„s� .-fUIf r�2M Phone l 7400 cs17 -Contractar f Address License No.1&2,3 73. Phone + TYPE OF WELL/PUMP: �..,.;; NEW WELL ;, WELL REPLACEMENT' [7 DESTRUCTION ❑ Out of Service Well ❑ -- -- =�--- ---e PUMP INSTALLATION ($�, `. ..-- �•.-SYST•EM_REPAIR-CJ--- - - ---OTHER-0-_OTHER❑». T Monitoring tire11 yL� �,.,DISTANCE TO NEAREST: SEPTIC TANK !-f SEWER LINES e�2L'L DISPOSAL FLD,.�'PROP. LINE —1-5Vrt � y r ar ti,f- "^ FOUNDATION ��AGRICULTURE WELL —90—OTHER WELL �' Q ^'-;PITS/: Sl1MPS INTENDED USE TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICAI'EONS_ Inductrial ❑ Open Bottom ❑ Manteca Dia. of Well E�ieavation .../ pia, of WaII Casing U Domestic/Private ffl Gravel Pack t - - ❑ Tracy i Type oltC"ing 5_ Tficatioria ' 6 Q Public 171 Othef �Dtpth of'GrouY Seak - � - Q�fy trout i CI IniOatron4�Approx, Depth t� ❑� '�astern, a Surface Soul Installed by , Repair Work Done 0, Type pf Pump � H.P. _ . �� State Work Done 1 t Well Destruction 0 Well Diameter Sealing Material i Depth . Depth -FS11er..Materlal�.i.,Depth..� 'r"� '� -_ -- TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is 0 available within 200 feet.l Installation will serve: Residence Commercial_,_, Other Number of living units: , Number bedrooms d Character,of soil to a depth,of 3 feet: �5EPTIC TANK. \l -��' Water table depth d, �Type/Mfg Capacity No. Compartments Y PKG. TREATMENT PLT: \ Disposal 1 Method of Di Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of linos Total length/size FILTER BED I1 Distance to nearest: Well t 'F.ounda Property Line '` ! E SEEPAGE PITS %ADepth Size? -%t_ \ �. mbar: SUMPS LI Distance t Barest: Well Foundation " oparty Line DISPOSAL PONDS ❑ I hereby certify that I have:prepired 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.Josquin County Home owner or licensed agent'sisignaiu►a 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 manner as to become subject to workman's compensation taws of California." Contractor's Kirin@ or sub contracting signature N Certifies the followin : "I cirtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's tompansa tion la aliforn t The apklicant m at or all rs n ampl a drawing on "rj# side. f Signed — / Title: Date: OR DEPARTMENT USE ONLY ` Application Accepted by Date__ Ares —� Pito Grout napsction by Data O Final Inspection by to - --TF Additional Comments: � -'�.. _� - �� Applicant - Return cop o: JOAQU N CO T ELIC HE TH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES t'-viii 445 H SAN JOAQUIN, P O BOX 2009., STOCKTON, CA 8520 FEE AMOUNT DUE AMOUNT REW3Treo CK RECEWED 9Y INFO CAS,, DATE PERMIT NO. . EN 17-24 fREV,Ein61I ski � .� - Ck 1 -may 1 tP �'