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APPLICATION SR # SAN JOAC UIN COUNTY PUBLIC HEALTH SERVICES VIRONMTAL DIVISION AID # 445 N AN JOAQUIN, PHONEH (209)468-3420 FAC # BOX 2009, STOC%TON, CA 95201 b l 3 Z R R DATEISSUED INV#_ 5 a'� (Complete in Triplicate) Applicattop In terouaty fors permit to construct and/or install the vork herein described. This application Is aside in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County/.,Public Health�Sler/vices. �{�7 Job Address _11' ' ,V Cir t Size/Acreage L*9 r t w"i Name Address V f Phone r Contract /� Address / S License No. S-3 Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT CT DESTRUCTION ❑ out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Excavation_ Dia_ of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy T of sing__ Specifications 1'I Public 1".1 Other 11 Delta Depth o Grout Sea: Type of Growl I I bnpnion _Approx. Depth I I Eastern Surfac Seal Instal by Repair Work Done ❑ Type of Pump H.P. _ Stela Work Done _ Wall Destruction ❑ Well Diameter Sealing Nateri►1 a Depth Depth Filler Naterial A Depth TYPE OF SEPTIC WORK; NEW INSTALLATION Irl REPAIWADDITION I DESTRUCTION 11 (No septic system permitted it public wwer is r / available within 200 feet.) Installation will serve: Residence✓ Commercialther Number of Ilving units: _ Number of bedrooms Character of soE to a depth o1`13 fest: Water table dept - SEPTIC TANK ❑ Type/Mfg r iso PCapxity U V No, Compartments PKG. TREATMENT PLT.❑ J, _� Method of Disposalyy Distance to nearest: Well �r\tea!/f-- Foundation Property Line LEACHING LINE ❑ Na IF Length of linea .� �To I�long th/size FILTER BED ❑ Distance to nearest: MIA 1171P Foundations ,✓L Pro Line SEEPAGE PITS 11 Depth "%-Z/ Sire ber SUMPS LI Disynce to n nst: Well oundstionProperty Line DISPOSAL PONDS ClI hereby certify, that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin County - Home owner or licensed agent's aignNure certifies the following: "I certify that in the performance of the work for which this permil is issued, I shell not employ any person in such manner as to become subject to workmen's compensation laws of California."Contracsm's hiring w sub-contracting signature certifies the fotlowing: "I certity,that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compares, lion laws of California." The applicant me *11 for aR rqq ed inspectio . Complete drawing on reverse side.. Signed Title: Date: FOR DEPARTMENT USE ONLY f Application Accepted by (� �� rer-+� - G Date /1 Area r 09or Greet Inspection byy�,f�7 �cfr� Date Final Inspection by _/�� Additional Comments: r--- Applicant - Return all copies to: Sen Joaquin County Public Health Services HYV1 rOnmen tel Health Permit/Services Bov N San Joaquin, P O Box 2009, Stkn, GA 95201 FEEO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT No. INFl t , EN ties lltEv.Irn e EN t �L� /(7�a(� V— �1 �,38� Ib� \\ mac.