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ET N PERAIT TZs; ` APPLICATION FOR PERMIT SAH JOAQU I N COUNTY PUBLIC HEALTH SERVICES p ttni,e'Tiz M I31k-BI f�f�� �NT ENVIRONMENTAL HEALTH DIVISION 3 i'7(� I p�0 U-: - 13"'J9,7, PAY 1 2t""it- 0 BOX 2009, STOCKTONI, CA 95201 a a�sT s aG2�lu f A te`+r RF-CEI (209) 468-3447 Y 4 PERMIT IRES 1 XBAR �R A DATE ISSUED t ) � SAS JO COUN'P1 (Complete in Triplicate) LSH S k AAA �rJC c F'l� o4kE �' �,to Seri Joaquin County for s permit to construct and/or install the work herein described. This - ft Vf on is made in compliance with San Joaquin Count Or;&inan a No. 549 and 1862 and the Rules aad Regulations of San Joaquin County Public Health Services. I{� � _ gip►i I orr e-sa n*t- vA LL.1 Y " Job Address IN+ O%` %AL' iZ� � ill-VO-11 City S 1�� Lot Size/Acreage r Owner's Name TSS =W.MP-pp�oAdd�ress &S €l_pEa "M It PJAO PhonYl6 38 t=-mcci SA A14ANfP i Ll 276 Contractor['&�i ' iL-�ti1�Z.. Address ' �3 oM 4 44fkLL-F_' SALTCA &1iti N0. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ID PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well [3 DISTANCE TO NEAREST: SEPTIC TANK �flA` SEWER LINES DISPOSAL FLD. NLA PROP. LINE µ_FQUNDATI.ON -N� AGRICULTURE WELL_ELO�_ aTHER_WELL ._".-PITS/SUM PS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'i Ll Industrial ❑ open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing 4 U Domestic/Private 0 Gravel Pack L1 Tracy Type of Casing Specifications i M Public f".l Other ❑ Delta Depth of Grout Seal Type of Grout m M Ifrioation 4 Approx. 'Depth ❑ Eastern Surf ace Seal Installed by r Repair Work Done U Type of Pump +i H.P. State Work Done a Welt Destruct' O'�Diametar- � Sealing Material i Depth a ��11t1JT" � i'�i�.nS�taLT� ��k' ' ��G��C.t1rJ; Depth ��"�t Filler Material i Deptri �� 11. 1r►i'�lr� � Cxstwlli l b� TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIRlADDITION Lf OESTRUC71oN GI INo septic system permitted if public sewer is , available within Z00 teet.l �' Installation wilt serve: Residence�� Commercial_____ Other - - -- Number of living units: Number of bedrooms Character of soil to a depth of 3 fest: I Water table depth w SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal r Distance to nearest: Well Foundation. Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED n Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I,,Depth'09' Size- Number SUMPS .,w LI Distance to nearest: Well Foundation__ It `Property Line DISPOSAL PONDS ❑ I hereby certify thatI 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 rnannAr as to become subject to workman's compensation laws of California." Contractor'i hiring or sub-contracting signature certifies the fallowing: "1 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 mus iii for all ri ed ins in s. Complete drawing on reverse side yy�/ i� i` J/ILS, Signed x� f Title: _ 5'AFF � Date: F R DEPARTMENT USE ONLY Application Accepted by Date r� Are& 4211 Pit or Grout Inspection by Date Final Inspection Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /V[ `C fay r ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT NO, INFO • EN 13.21 IREV,tint! �� " EM "1.20 k +