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APPLJCATIONt FOR PERMIT BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL "AZ'1H DIVISION F 0 BOX 2009, STOCKTON, CA 95201 (209) 468--3447 RIs 1 YEAR r90M D (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 Ccm,>pliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules end Regulations of San Joaquin County Public ' Health Services.__� Job Address :_�_ L /,+�- Zf City u. Lot Size/Acreage - ,( 1 Owner's Name � G{ �`CC� i Cij Yrs, Address Phony [ t i7 Contractor 6_CC/c& LJse',41" i>ra}v Address _I I°Ci License No. 1 1 . Phone TYPE OF WELL/PUMP NE'Jd WELL HELL REPLACEMENT DESTRUCTION jc1 Out of Service Well ❑ PUMP INSTALLAT �I/ON C SYSTEM. REPAIR [ OTHER O Monitoring Well C� DISTANCE TO NEAREST. SEPTIC TANK !ii co s'- SEWED LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRiCULT'URE WELL OTHER WELL PITS/SUMPS ____ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT#ON SPECIFICATION ffir T", Industnai pen Bottom ❑ Manteca Dia. of Well Excavation Dia of Well Cesin U Domestic/Prvate Gravel Pack rTracy Type of Casing_ 1 _ pe rr v ]`-ft f S crlications 0 PrtDlic CI Other 0 Delta Type of Grout, '-� Depth of Grout Seal � � T fee t XLrnUa(ion Approx. Depth 0 Eastern Surface Seal installed by_ ✓4 Repair Work Done J Type of Pump a H.P. 011 A to Work one Well Destruction O Wal( Diameter { Sealing Material & Depth Q rr PC, rr' Depth _ _ — Filler Material i Depth Sr e+` ora ra d' / )Q, 4,-t ' TYPE OF SEPTIC WORK NEW INSTALLATION L-1 REPAIR1RDQtTION Li DESTRLCTION [D INo septic system permitted A public sewer is w available within 244 feet.i 4— Installation will serve: Rovdence — Commercial --__ Other Number of living units: Number of bedrooms --- f Character of soil to a depth of 3 feat: _ Water table depth_-. j SEPTIC TANK [# Type/MfC2 Capacity_____ No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well _�__ Foundation _ Property Line LEACHING LINE C Nti. Et Length of lines _ � Totai length/size � FILTER 6FD Cl Distance to nearest: Well _-- Foundation --- Property Line SEEPAGE PITS II Depth Size __ . _ Number SUMPS L1 Distance to nearest: WeliFoundation _. _....._.- Property Line DISPOSAL PONDS 171 I hereby certify that I have prepared this appkcatinn and that she work wlil be done in accordance with San Joaquin county ordinances, state taws, and rulss and rogv;attune of the Son Joaquin County Home owner or licensed agent's signature certifies the foltow g "I certify that in the pedo+rnance of tree work for which this permit is issued, I shall not employ any person in such manner as to becorna subject to workmen's compensalton laws of Cahlorni'n." Contractor's hiring or sub-Contracting signatuio certifies the following: "I Certify that in the performance of the work for which this permit is &sued, i arsatl omploy persons subject to workman's compensa tion laws of CoIiI�H�H." The applica must calil f all�e u ed inspections. Complete drawing un ray ria s da � / .: Signed X " �` Title 12'' Rafe:_ FOR DEPARTMENT USE ONLY Application Accepted by _ ✓ _ ___�_.. r __.� _ Data .__.. 0. Ares Pit or Grout Inspection by Date Final Inspection by / _ - `AdditivnSl Cornrri'nF$: .I,rL r _`FfE.. ,,,1- �r s . �u.c .LcfY zfi-� Applicant - Return all: cal r.o< SAN JOARfJIff RUNTY PUB LL1-rt RL ERVICES ENYIRONWF-NTAL HEALTH DIVISION PERMIT/SCHviCRS 445 N `:Alit JOAQUIN, P C BOX. 2008, STOCKTON, CA 95201S+f-�,2 _ ,Y PEE 1 INFOAMDU:'!-DUE AhaOUNT flFM1kiT i FL7_ CA5M RELfIVf[7 c1Y � DATE --T-��-PEF�7�.S1 i WN07_ r - EW 13.74 tAEV „Ks>> ( I 'I .r .rr' i ............................................................................................................ ................ ____-........