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I 4k- APPLICATION FOR PERMIT OL-b Fo�-OD � -6 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT MWIRES 1 YEAR FROM DATE ISSUED n (Complete in Triplicate) Application 1s bereby made to Ban IJoaqufa County for a permit to construct and/or lnstsll the vork herein described. This application 1a made in compli nce vlth Sm Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public_Health Be" e5. J a � I r V✓ City Lot Sl to/Acreage Job Address T I, _J� / � Address Phone Owner's Na '' // A ^ u �p.LL fD ( ddress vicense No. d- Phone S Contractor _ TYPE—OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Yell PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Ibnitaring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE fFOUNOATION AGRICULTURE WELL OTHER WELL '- PITS/SUMPS _ 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Induairiel ❑ Opsn Bottom D Manteca Dia. of Well Excavation Dia. of Wall Cisirq ❑ Domestic/Private ❑ Gravel Pack D Tracy Typo of Casing_ Specifications I Public D Other fT Della Depth of Grout Seal Typo of Grout I I litigation _Approx. Depth I I Eastern Surface Soul Inauped by State Work Done Repair Work Done L] Type o1 Pump H.P. _. Well m Destruction D Wolf Diaeter Sealing Material L Depth Depth 1111er Naterlal a Depth ^ TYPE OF SEPTIC WORK, NEW INSTALLATION I I REPAIR/ADOITION 5TRUCTION I I availseptseptic SVIt m lmilteu it pubic sewer is Installation will serve: ResiQence '— commercial Other Number of living uniu: ---F/— Number of bed/rgpm�a - Character of sola to a depth of 71MC1 XtST�1Water table depth I ^, Capacity m No. Copartments SEPTIC TANK ❑ Type/Mfg tl Method of Disposal PKG. TREATMENT PLT.D f m __Distance-to.Reas: Wall, _Eoundetion T = Property Lim I I 1 � �� LEACHING LINE f]�Ho'. gCength of lines 5O 6L Total length/ei2e I FILTER BED D Distance to moron: WellIP 4,,. Foundation�(7�- ..PropoM-Line i BEEPAOE PITSePin f ��.� She ` Nmber r SUMPS Ll Distance W nearest: Well Foundation Proporry Lits.1 n DISPOSAL PONDS ❑ I `I __ _wi/ f �.1� /,r-C" I hereby certify that 1 haw Prepared thin application and that the work n be done in accordance with San Joaquin county ordinances, state Jews, ond7) rules and regulations of the San Joaquin CodntY Homs 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 :hall not employ any person in such msnnw as to becoinst aublect to wbrliman's_comp;�Mation Iowa of California." Contractor's hiring or sub-contracting signature unifies the following: "I cartify,that m the perforrtienu otthe work for which this permit is iswed,\II employ Wrwrn subject m workmert's comPenu cion of Calilor s The c at c , for Iraq rod." I R Complete drawing o/n verse std a S m 6 Title: _S/e � Date:V r © r F@\q\DEPARTMENT.USE_ONLY Date 3 Area --AppliUtiGn Atteplid by �-- Pit or Grout Inspection by Date Final Inspection by Date ` Additional Comments: Applicant--Return–ail–coDlea–to:—Environmental Health .r-itlealth–Servit' y Environmental Health Permit]Services • .445 N San Joaquin, P 0 Bok 2009, Stkn, CA 95201 r aFtnAMWNT BEMIRED CK RECEIVED eV DATE PERMIT'N0. CAS. AFH ta24 IREV Fri 14311