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Ig APPL I CAT I ON I FOR PERM I T I SAN '..... AQUIN COUNTY PUBLIC HEALTH ICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 - J f (209) 468 3 yea A - P $4[LT FIRE4S 1 YEAR PROM JDTSS Q (Complete in Triplicate) �,� �L 1 C4) Application is hereby rmde•to San Joaquin County for a permit to construct and/or, install t�brrk hereitt✓pdescribed. This application is made in eoe>pliance with San Joaquin County Ordinance No. 549 and .1862 and the.;Rt} & Regulations of San Joaquin County Public Health Services. / Y�i�/,�SV/j Job Address (] G�'R't //, d _City TALr/ - Lot Size/Aere�ay�Q Owners Name .Sou�t tC?6,4 , , „ Address' /6 f"' ! c Phone 6 — V30 €� L, � n r k�r5 e� ,. Contractor ?�� lr IR Address i , t13o License No.C-- SQSZIO PhonezO'1-5T6fl-O z-1 TYPE OF WELL/PUMP; dNEW WELL ® WELL REPLACEMENT ❑ DESTRUCTION L� Out of Service Well 0 iI PUMP INSTALLATION 0 _ SYSTEM REPAIR ❑ OTHER ❑��Roaitoring Well � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �� I'f FOUNDATION 'L.O AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF'IWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rl n Indtistrial '❑��Open Bottom ❑ Manteca Dia. of Well Excavation [0�r Dia. of Well Casing IN DomesutlPrivate ;I tl&avel Pack A Tracy Type of Casing PSC Specifications M Public I:1 Other ❑ Delta Depth of Grout Seal l/vi Yet kv%D1J'L*" Type of Grout H�arti�+u�f it 0 IrnUation Approx. Depth O Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump .LJejJ,C_ H.P. i' State Work Done_ Well Dlestruction ❑ Well Diameter ��. Sealing Material i Depth S' 6.,tfo.�.fa J/aP�R�t.#�d -{pfrca I Depth—4. t Filler Materie,116, th TYPE OF SEPTIC WORK; NEW INSTALLATION L3 REPAIR/ADDITION M ;OE RUC7 ON G (No septi systam perfnitted if public sewer is {Fr i available within 200 feet.) . installation will serve: Residence—L Commercial— Other Number of living units: " Number of bedrooms Character of soil to a depth of 3 feet: Water tab depth SEPTIC!TANK. O Type/Mfg Capacity. menta PKG. TREATMENT PLT. ❑ V Disposal € V ;. Dislance to nearest: Well Foundation Pr one LEACHING LINE Cl No. b Length of lines of lengt /si:e FILTER GED n Distance to nearest: Welt Foundation Property Line SEEPAGE PITS i I Depth Sire Number SUMPS, Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J !i I hereby.certify that I have prepared this application 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 agent's signature certifies the following: "I certify that in,tha performance of the work for which this permit is issued, I shall not employ any person in such manner as to:become subject to workman's compensalion laws of California." Contractor's hiring or subcontracting signature certifies,the following: "I certify that in the performance of the work for which this permit is issued, I shag employ persona subject to workman's compensa- tion laws of California." The applicant mu t call for all required ins ti s, m to drawing on reverse'side.: 3 Signed AI Title-� � aa""!' q 4A Date: ! L FEPAR T [1Si: ONLY .�i,74/ I rte- " Application Accepted by Date t i Plir;pr Grout Inspection by Date � Final-inspection b Date A<Wt+on6l Cor7I-ments: Appt - Re:;ura a31 ooplee to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /lO ENVIRONMENTAL HEALTH OIVISION`-PERMIT/SERVICES Vx 445 N SAN JOAQUIN, P O BOX 2009; 3TUCKTON, CA 95201 /O �C�Y�F%,�FQ AMOUNT DUE AMOUNT REMITTED CASH RECEIVED $Y CK 9 _FDATE PERMIT NO. + EM 13.24 UIEV.1i w 51 'y — EN A'X i �;