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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FRO-DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin CountyPublicHealth Services. Job Address { `I S�S IS J51Q&A,6 �QU d—— Cit Lot Size/Acreage Ow is Name M U�bQ%dress tw��-�--�, Phone 89 '' -46nse NO.Ak&1�2 PhoneQ TYPE OF WELL/PUMP: NEW WEL WELL REPLACEME T ❑ DESTRUCTION C1 Out of Service well ❑ PUMP INSTALLATION t SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ j DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD. PROP. LIME j FOUNDATION Y AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL r,-PROBLEM AREA ;CONSTRUCTION SPECIFICATIONS L] Industrial ❑ Open Bbnom ❑ Manteca Die, of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Back L7iTracy F _Type of Casing Specifications f 1 Public 171 Other -1 Delta �,� Depth of Grout Seal Type of Grout n I I Irrigation ___.Approx. Depth I� � �I Eastern �/Surface Seal Istalled Repair Work Done U Type of Pump _,, H.P. z I State Work Do9 .1 Well Destruction O Well Diameter _ Sealing Material li Depth r,1 1 1 Filler Materiel a Depth r } "' t 1 r u R Depth �-M M __ _ _ ___ _ TYPE OF SEPTIC WORK: .NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I JNo septic system permitted if public sewer is f, ^ available within 200 feec.l ni Installation will serve: Residence_ Commercial_ Other a ; Number of living units: Number of bedrooms Q ' Character of soll to a depth of 3 feet: W Water table depth SEPTIC TANK. ❑ TypalMfy Capacity No. Compartments PKG. TREATMENT PLT.0 , Method of Disposal Distance to nearest: Well Foundation 1 Property Line LEACHING LINE ❑ No. & Length of lines Total length./size FILTER BED ❑ Distance to nearest. Well Foundation Property Line i SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 cartifies 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 workmen'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- 41 tion laws of California." o y The applica gust call r 11 r uired inspections. Ca to drawing on revW side. A Signed - _- Title: Date: t Oti DEPARTMENT USE ONLY Application Accepted by -RAA& r AAAA k,Mlf� Date � Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: x Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IEEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EM 114 IIIEV.t/N51 t 0-0g Z'�� r EH t1.7ti t�