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�r APPLICATION FOR PERU' SAN O QUIN COUNTY PUBLIC HEALTH S MVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, 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 work herein described. This application is made in cowllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address J191loliillr 155-r iL, qEV a ,City Lot Size/Acreage 1�� ! Owner's NameucAatj smlk �ss ?4 Boy, M.'i `Phone Q� *4217912--_ Po Contractors .a � � ?rsr7O SX ] TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLAAT`�I'O�N ❑0 SEWER LINES DISPOSAL SYSTEM REPAIR ❑ //0�TJJrr//EER)(PRONon Well ❑ DISTANCE TO NEAREST SEPTIC TANKPLI FOUNDATION � AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack Tracy Type of Casing_ _ Specifications I'1 Public �ther t1 Delta Depth of Grout Seal _ Type of Grout I I Irrigation LOApprox. Depth I I Eastern Surface Seal Installed by 99EWA Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material t Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION 1 11No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other W Number of living units: _ Number of bedrooms Character of Boll to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r— FILTER BED ❑ Distance to nearest: Well Foundation Property Line c— SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 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 manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting 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- tion laws of California." The applicant m ca0 for ell required ' pections. om Is drawing on reverse side. Signed Title: <A- 7 � �d2 3 Date: �� 3 FOR DEPARTMENT USE ONLY ST' Application Accepted by r /1 Date ' 9.3 Area 2 9-0 Ph or Grout Inspection by Date Final WwpAQJj9P by TBMDate 1Z ` Additional Comments: V 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 INFR0 AM(7OU1UNT7�D]UUE AMOUNTT REMITTED CASH RECEIVED BV DATE L�PjERMIT NO. . IN 1124 taEV.1at sg U 1VIl 1.�� v �y,w, �'2� 93 rJ•o R59 EN/4.11