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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 L P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appllestlo4 is hereby made to.San Joaquin County for a permit to construct and/or inatall the work herein described. This application is made in Coetillaace with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 6115-6 Zile-Tb `"Ll0t,;el City is �'� ' t 91ze/Acreage GS OA Owner's Name 15,71 /✓1.6� (p.C�� Address O f Lr+^m��.-r/-�P�hone Address ! � /a +C�y' o Phone Contractor ' License N TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ Monitoring Well ❑ '-DISTANC'�TD NEAWESf:`SEPTIC-TANK SEWER-LINES -DISPOSAL-FLDr -PROP-LINE-- -•� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of War Casing O Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications it Public ❑ Other -`-47 Delta__ I-- Depth of Grout Seal Type of Grout 1 I Irrigation _ApproK. Depth '1,1 Eastern "' Surface Seal Installed by \ ,� Repair Work Done ❑ Type of Pump H.P. State Work Done_. V Wer Destruction ❑ Wer Diameter Sealing Material i Depth Q Depth filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION 1 I, INO,s6atic system permitted it public sewer is V evakabwm' 'thin 2W feet.) gyp, Inttsration.will serve: Residents.�ommercut_ Other Number c1 kvv+p units: -IL Number of bedrooms .- Character of soU to a depth of 3 fest: A dg a'- - -Water table depth SEPTIC TANK. ❑ Typellift L r Cspacity Za�'L) No. Compartments Q PKG. TREATMENT PLT.❑ Method of Disposal - Distance to nNrast: Well �Foundation .!LG-_ Property IJna Q LEACHING LINE No_6 Length9f,ligula Total leng[h/sae. y FILTER BED ❑ Distant°to nearest: Well l%�1 Foundation 60� Property Line SEEPAGE PITS aptR fi�$� Sired ~_— Number - SUMPS LI Distance to merest: Welll�n Fx�Foundstion"�0 -Property Lira DISPOSAL PONDS ❑ "`"'- r•"`t { 1 hereby cavity that 1 have prepared this application and that the work will be done in accordance wiih`San'Joaquin county ordinances• state laws, and rules and regulations of the San Joaquin_Couoty .,'4 - _ ._ j - Homs owner or licensed agent's signature Certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall rat _ employ any person in such manner As to become aubjacrid,workman's compensstion taws of California."CoAtractor's hiring Or subcontracting signature cartiliea rho following: "1 certify that in the performance of'the work for which this permit is issued. I$hall employ persons subject to workman's compensa- tion laws of Calromla." j� The appllrAM rtwat call for requk +nepgctiona'Complete drawing on reveres side. Signed X_ r� + 'Tit+e i .d -� Date_ t , FOR DEPARTMENT USE ONLY A cetion Accepted by """� ---Date res Grout Inspection by Date= ^'FinalInspection by Data- � � Additional Commanta: Applicant - Return all copies to: na Joaquin County Public EResServices + 4451 roembn tel Health Permit/Servery ices 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 -FEEAMOUNT Ot/E AMOUNT flEMI1TED K flECEiVEO 9Y" DATf PERMtt'NO. INFO CASH . EM 1124laEV,vxnt -1213 -