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,m i APPLICATION FOR PERYIT� *; (/ SAN JOAQUIN COUNTY PUBLIC! HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCXTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compilaoce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. c n Job Address �T` C Ala S-T 'r,�1� `�Tlz (C7l-F Cit TK noy. !Lot Size/Acreage Z /"/� t J �' V Gi71V l OVI'r Ll-- .i� �GS Phone�bQt}I(G(� Owner's Name p' U Address �� ,��,'tn Contractor s 15 -340 1 `� �v Address FQ `�� 13�L" rt,/7Q cre��ryo. Phone 4�&1Z5i#1 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHEf� Monitoring Well ❑ a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ''�I DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS SMP, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS SO='I 0 Industrial ❑ Ocean Bottom ion _0 Manteca Dia. of Well ExcavatDia. of Well Casing &P-1 >eDomestic/Private ❑ Gravel Pack Pdracv Type of Casing ll Specifications_7IItq - , I'1 Public Ther 1l _Delta Depth of Grout!,ISeal Type of Grout ,t'' aJ-- I I Irrigation U '0- Approx. Depth I I Eastern Surface Seal Iniulled by � Repair Work Done U Type of Pump H.P. l- S{1Apte Work Done Well Destruction 0 Well Diameter Sealing Material A Depth /}&An-b IV/M ZV=T Depth !/� / Jr Filler Material A Depth PO1Z-Oy N 10 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is Y�1 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms - Character of soB to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity) No. Corhpartrnehta PKG. TREATMENT PLT.0 �',I Method of Dispos� Distance to nearest: Well Foundation Property Lie NT LEACHING LINE ❑ No. 8 Length of lines Total length/size - FILTER BED ❑ Distance to nearest: Well Foundation '.� Property Lie I 1993 SAN 1[ICOA IN COUNTY SEEPAGE PITS 11 Depth Size '�� Number VICES EALTjj DIVISIO SUMPS LI Distance to nearest: Well Foundation /I Property Lie DISPOSAL PONDS 0 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 San Joaquin County iii 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 subcontracting signature tartifi"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- ' tan lawn of California." < The applicant_Wt call for an r uired inspections. Complete drawing on re rse side. I,I ,�/ Signed ��Gh if �,( �y� y Title: r �fJ� Gr /oy(�� Date: //� "i✓ / Al NA G FOR DEPARTMENT USE ONLY % I Application Accepted by .� � '=f-I Date Area Pit or Grout Inspection by Date Final Insprection by Date Additional Comments: �II Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 20`9, Stkn, CA 95201 RT INFO AMOUNT DUE AMOUNT REMITTED CASSH RECEIVED BY DATE PERMIT'NO. . EH,4.29 v.,/nal 00�D �,Pl ' � `b / �-2t9 2 EH,C m