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APPLICATION FOR PEP-MIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SER'VICESIV- , EN V I RON31tENTAL HEALTH DIVISIONrt- ±-` J>t f f 7 w L P O BOX' 2009, `STOOSTON, CA 9520 Tit (209) (209) 468,, 3420 C vote ry ' YEAR '(Complete in 'Triplicate) .. Applica[:on 1■ hereby toads Lo 646D Joaquin County Sor a permit to construct and/or lnatall the work herein defscrlbe'd. This appllcatioo Se sande in t:oaspllance with San Jcwquin County Ordinance No. 549 and 1862 and the Rules end Regulatlond` of Sun Joaquin County Public Health Services, Z i4PN P JOU City Lot-Size/Acreage ownel's Name P-0' Address! •Q aK 8� "f M i Conllaclo, ` Ao.r6dx 1r,2•d--9� Address iG � Llt ercse No.�Q�Jr'G$ Pn7 one �&�- TYPE OF WALL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] I - DESTRUCTION Ci Out or Scrvlcc ucll 0 I PUMP INSTALLATION ❑ SYSTEM:REPAIR [1 OTHER �' Mo tto�ing cell DISTANCE TO NEAREST: SEPTIC TANK SO �rb6cs f'7 �J�. SEWER LINES /0 ' ` DISPOSAL FLO/%,� PROP. LINE _ FOUNDATION ., AGRICULTURE WELL. ./✓/f7 OTHER WELL /0' PITSISUMPS ,4!4 INTENDED USE TYPE OF WELL PRO.8LFMAREA CONSTRUCTION SPECIFICATIONS i.l Indvsuial ❑ Opan Bottom p Manteca pia. o1 Well Excavation —� Dia. of Well Casing xDOMOSlic/Psivale L7 Gravel Pick r ❑ Tracy T o G C Type of Casing Sfxcifications -2 Publ'`c 1SrYDthor ❑ Delia - r Depth of Groul Seal ��r�.-rl✓ Ls � Type of Grout �I Ir+Uel on 1�.Approx. Depth ❑ Eastern Surface Sabl instsllnd by. i'_C.6s- Rnoair Wort Done U Type of Pump H.P. Stora Work Done Well Destrunion I0 Well Diameter ` sealing 11R retial' L Depth Depth P111eir Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I3 REPAIR/AbOIT N Ll DESTRUCTION G (No septic syslnm permilted if public sower is available within 200 feet-1 R Inst:llalion will serve: Residence — Commercial Other w X11 Y Nvmbar of living units: Number of bedrooms j IF Character of snit to a depth of 3 feet: hF I SEPTIC TANK — - _, Water tebin depth ❑ Type/Mfg Capacity_-__ No;-Copa PKG. TREATMENT PLT, Cl mnnems ---• .Method o1 Disposal= - Distance to nearest: Well Founde"On PrOPany Linn LEACHING LINE - ' C1 No. $ Length of lines _ Total length/sirs FILTER $ED C1 Distance to nearest: Welt' ', Foundation =- Properly Line SEEPAGE PITS 11 Depth Sizef SUMPS Lk D"+stance to nearest: Nurnbar.Well v Foundation _ D15POSAL PONDS _ Propeny Line I nereoy Cenify Ilial I have prepared this application and that the work will be dono 'in Accc,ra4nca wish-Sart Joagvin county Ordinances, state laws, and rules and (■9ulalions of the Sen Joauuin County _ Home owner or licensed agent's signature cenifies the following: "I Certify that in1[ha fX)rnorrnunca of the work jot which'-this permit is issued, I shall nos employ any porion in $Vch manner as 10 become subject to workman's compensation laws-M Cslitornis," Contractor's hiring or sub•Conlrbcling signature cenifies Ilia following: "I certify that in the Performance Of the work for which this tion laws of Calijornla." permit is iUued, [ shall amp[Oy persons subject l0 workman's COmpensa- Tho applicant call 1 11 requir d inspections. Complete drawing on reverse side: Si,noU Title: "'' .Dols:. I�4 DEPARTMENT USE ONLY FOR APPfication A pled by c� �"�/ •7 i" Darn L J jArea Pit or Grout Inrpaclicn by Dateui ��. Final Inspocon by Date additional Comments; ^3 Appll"nt - Return all Copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION,PERli1T/SERVICES 445 N SMi'JOAQUIN, P 0 BOX 2009, STOCKTON, CA'95201 r' FEE N INFO AMOUNT DUE AMOUNT REMITT90 I RECEIVED BY -.DATE PE RMIT'ND: 13 IA(Y. w