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i • APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance With Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Addressgyl CharkA ACity s itys im!4.iv„ Lot Size/Acreage Owner's Name YfO Pm 1Ul V"SCOAddress P•d JOK581I Phone Contractor -SCMI C)!0_4 ,9YAddressM0 NOSSWO&Idrik License No. 1IWS _Phone A '65222 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O Monitoring Wellan ir tKt ftr- fmciYb, DISTANCE TO NEAREST: SEPTIC TANK SSD SEWER LINES [.S O DISPOSAL FLD.� PROP. LINE '!d FOUNDATION L-29— AGRICULTURE WELL ?-L0 OTHER WELL PITS/SUMPS A'A- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS yil ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation + Dia. of Well Casing r Domestic/Private Gravel Peck El Tracy Type of Casing_5(l-tl.lOFUC Specifications 1'I Public fl Other rT Delta Depth of Grout Seall Type of Grout boribl,11C I I lutgatfon _Approx. Depth Eastern Surface Seat Installed by/(f 11 e r .�(�� Repair Work Done ❑ Type of Pump H.P. State Work Done _ Wall Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of*oil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line y.7-T--T'�i SEEPAGE PITS 11 Depth Size Number c" I ' '"t; 111 ' SUMPS LI Distance to nearest: Well Foundation Property Lihi 11 I,; I it_ DISPOSAL PONDS ❑ 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 Sen 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 manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit Is issued, I shall employ persons subject to workman's compenss tion taws of Callfomla." The applicant at s.t�ca,ll�)o�r " r r inspect�i/o�ne. Complete drawing on reverse side. - Signed X IEM42Ll Title: �& _ I Date: FOR DEPARTMENT USE ONLY / g Application Accepted by Date Pit or Grout Inspection by /s7�T/t Date pinalll Inspection by Date f Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services O D Environmental Health Permlt/Services G 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 a FEE AMOUNT AMOUNT DUE REMITTED CK RECEIVE BY DATE PERMIT NO. INF-.O/ CASH / . EH 3.24(REV,1/s e) /// EM;4 is WWW J