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APPLICATION FOR PERMIT SAN .J OAQU IN COUNTY PUBLIC HEALTH SERVICES ENVIHONIBBNTAL HEALTH DIVISION s , 445 N SAN JOAQUIN , PHONE. (209)468--3420 __- P O :f30% 2009, SlrOCKTON, CA 95201 FRQY DAA' _.jd—MM. (Compute in Tripli+zate) A{�plication f.• Aareby nada to Baso Joareuin Cortnty for a permit to construct and/or install the work herein described- This application is made in compliance with 84.n Jow,puin county Ord.ina.nce No. 549 and 1862 Auid the Rules acct Reguiatione of sari Joaquin County Ptablic Hemillth Sari'iccs.Job Add(ostil n A17 _� lL�� City Lot Size/Acreage Phone — Owner's Name ---- 1, ,J.,�. -- �,�� 0 sC ,,.,.�/ License Nc.r�� Phone CGrtrdclOr �� ..4a.-"" A08rtss _��.�__—_._�__._1Jr..l{.�r` TYPE OF Wf.LLrPUMP: NEW WELL G] WELL REPLACEMENT' (1 DESTRUCTION Cl Out of Service Well Cl --� -- PUMP INSTALLATION G SYSTEM REPAIR 0 OTHER [1] monitoring Well r� DISTANCE TO NEAREST: SEPTIC TANK SEWEA LINES DISPOSAL FLO.___-_._ PROP. LINE �w--�—Y- FOUNOATION AGRICL)L_TUAE WELL ____ OTHER WELL _— PITS/SUMPS _ INTENDED USE TYPE OF WELL —PROBLEM AREA rONSTRUCTION SPECIFICATIONS _ CJ Industrial - O Open Bottom G Manteca D±a a! Wall Excavation_— —____ Dia. of Wait Casing 1 Domestic:/Private O Gravel Pack 0 Tracy Type of C•arng_------_--- -. Spectficaitons-- 11 Pe,b0c 1-1 011ier Cl Delta Depth of Grout Seat .___._---_.. -_._ Tyfs• of Grout_-...—_,-._.. I I (ration ._._ Approx. Depth I I Eastern Surfscs Seat Installed M___ -----•------- �4 Repair Work Done LJ Type of Pump H.P. __.._. — __� _ Stat• Work DoneWell Destruction D Well Diameter _ 64*11ng iKt►teri•1 Depth _____� --• a" Depth Filler Material 4 Depth „___ —•...��— _ �._ EPS TYPE OF SEPTIC WORK: NEW INSTALLATION RLQ TPA R/ADOITION I f DESTRUCTION t I iNo-sep±rc system permitted if public sewer is (' I. avaitaois within 200 feet.I Mlf o4tall•tion. serve: Residence.— Cwrrmerciel Other Number of living units: _ Number of bed,00rns _. Chsractair of sod to a depth of 3 feet: Wet•r labiledepth SEPTIC: TANK U Type`MOg - L —_ Capectty_WAX-WAXNo. Compsetngtnts PKG. TAEATMENT PLT.O �� Method of Cisposa- Distance to nearest: Well .uZ4L Four4 lion Prc;perty Line LEACHING LINE Ci No. A Length of lines 7=f=#— ��W _ Tectal length/siz•_.-__. FILTER BED M Distanea to nearest: Wed� Lam' Foundation —_- Property Line SEEPAGE PITS 11 Depth _-- „—.-Size _+� . �Number SUMPS L.I Distance to rieareat: Well Foundation —. Property Lino DISPOSAL PONDS PONDS CJ I hereby eenify that I have prepared this appiesaWn and !hat the work wiil be done in accordance with San Joaquin county ordinances, state Jaws, and rules and regutstio,a of the San Joaquin Ccunty Moms owner or licsnstd agent's signature osrtiG"the foNowing: "I comity that in the periermance of the work for which this porrnit is rasued, 1 shall not an4UGy ony person it such manner as to becorr,e suc.prcc to workman's compensation laws of Cailcitnis." Curare:tor's hiring or suDcontrar_-ting signalurs certifies the folioliving: •'!certify that in the parlorrlwnro o'the work for-which this permit is issued, I shall employ p. coons subject to workman's compensa tion Iewv of cadfornia.'• TKO applicant must cap for/4111 requ,ed inapoctions. Cori)Oete drawing on r er r tri-�_ Signed Title: _ �,�„�{c•'�5..:�__ ___.__.—_ Ootet: __�!� FOR DEPARTMENT USE ONLYApplication Accepted by — _ Vat• L(- _��Z' Area Z ( (i: r G•pput,�EE do by _ — — Dau `' Ib Final Inspection by_..__ " ' "' `` -- Date_`5 !r Atidkkyrrel ....-- Ap+pllcant, - Return all copies to: Sa.a Joaquin County irubllc Health Servl�,,cr Bnviroomental Health Permit/ServiceN 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 SEE AMOUNT DUE AMOUNT REMITTED 7� Rf CIF!/ED AY DATE PERMIT lV0~ i INFO __ — - _ CASH C -_Y -JLf5 _ . - u�'. � 1- 370