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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I1\ ENVIRONMENTAL HEAITH 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 is hereby made to tan Joaquin County for a permit to construct and/or install the-work herein described. This application is made In comillance vith San Joaquin County Ordlna�n,f�2je No. 549 and 1 and the tRules and Regulations of Sin Joaquin County �Public Health {Services. OL�C .10- s�O7 t- b�- ] 7 �Q QCe l _I job Addr.dA2 Rake r)t'h"d h 1-R t e [� �j City"Vd I Lot Size/Acreage Owner's Name 9/k e ^ i)P- Address C,�•1 �[�� -:P, 7 [_�IJ,4 r Phone 3 I�� jConitacl Adtlress R'•V.1�1�qH� [.`7A / Y License No� Phonez6aq ,TYPE OF WELL/PUMP: NEW WELL]"a'' WELL REPLACEMENT>< DESTRUCTION ❑ Out of Service Veli. PUMP INSTALLATIONX- SYSTEM REPAIR C1 - _OTHER ❑ Monitoring Ye11 e DISTANCE TO NEAREST: SEPTIC TANK JYp nL° SEWER LINES DISPOSAL FLD. PROP.'L'INE-J62� , FOUNDATIONT AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TI S 10 t! Xindustrial ❑ Open Bottom' ❑ Manteca Dia. of Well Excsvation Dia. of Well Casing 11 Domaslic)Private >91 Gravel Pack 1 ❑ Tracy Type of Casing_ Specifications F1 Public I nn h1 O)her t fl Delta Depth of Grout Seal7yppp1eely��f o1 Grout plh Irrigation YO _Approx. OaI Eastern Surface Seal Installed by 9 t�2t , 1 ."A ' Repair Work Done 0 Type of Pump Z-> H.P. State Work Done _ •! ` Q Weil Destruction- O Well Diameter Sealing Material a Depth No - t Depth Filler.Material i Depth - ;TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I.(No septic system permitted i1 public sewer ill, L Iavailable within 200 lest.) II Instaltation will serve: Residence _ rCommercial_ Other�j t I Number of living units: _ Number of bedrooms l Charactsr of still to table depth to•depth of 3 fast: f ro SEPTIC TANK O Typa/M19 Capacity No. Compartments-1 PKG. TREATMENT PLT. L1Method of Disposal Distance to nearest: Well Foundation Property Line < LEACHING LINE ❑ No. a Length of lines Total length/size t FILTER BED ' ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth 1 Size-- Number SUMPS - LI Distance to natirast: Well Foundalion Property Lire t DISPOSAL PONDS ❑ I hareth, osnity that 1 have prepared this appkitiou 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 pant's signature certifies the following: "1 cattily 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 Calilornis." Contractor's hiring or sub-contracting signature unifies the following: "I unify that in the performance of the work for which this permit is issued, I shall employ persona subject to workmen's companss _ tion I@"of Califamis." The applicant t c puir inspections.49.n= CoComplete drawing on revere side. Sig C ,4Q^= _ Title: of �/L!�S Date: R DEPARTMENT USE ONLY Application Accepted by _ice^1,�.[... 7 Dots In-.ate 3 Ares "a '112 �_�N Pk a ou Inpection by "'tY`7�/��is 7-/-Z Final Impaction/b/y` ��- Date 1 Additional Comments: ^ t t .•,.-u� 4 -'i"'�- ' t /+�� /� /'� �AP Applicant - Return all copies to: San JoaquinCounty Public Health Services O ee �P.QQ ,riaf 445 N ,ementel Health Permit/Services s 445 H Sao Joaquin, P O Box 2008, Stkn, CA 95201 F�IN AMOUNT DUE S AMOUNT REMITTED CASH RECEIVED 01 DATE PERMIT'NO. fOc 1 Ct �y0 '1 • WS-D tN ii.i.tEv.treatA, 13 I . DC7 � 3. 1.76 a i i