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!� APPLICATION FOR PERMIT SAN JOAQUIN COUNTY, PUBLIC HEALTH SERVICTsS ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 13O% 2009, tSTOCKTONMAY 3 CA 9520.1 :' 119Q5 PE-WIT EXPIRES 11!YEAR FROl1[ D TE ISSILED >ENVIRONME (Complete E`i n Triplicate) PERMIT�SE JCESN 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 eattrplisnceery withservices. San Joaquin County Ordinance No. 549.and 11362 and!the Rules and Regulations of San Joaquin County Public Health Services. 6 L , �n Joh Address Gity tr., Lot, Size/Acreage ti/L!(1_ft /�s� T 7' ji 63 -0 .36 r Owner's Name h r r fra "b S.I Sir`o f Q.5 Address e e e 1 p�e p -Q 6 sic q :I t uwt 24 Contractor dress �25 r1le rLicense No.5 Z7-6 Phoi�Y*5- 7 Z TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of service We11 ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ !!OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK '1�+ SEWER LINES11, 30&d— DISPOSAL FLO.�t1dd� PROP. LWE1%C_f2 FOUNDATION !{5 AGRICULTURE-WELL &A— OTHER WELL_�L.``LGL,.,,. PITS/SUMPS INTENDED USE TYPE OF WALL ;PROBLEM AREA CONSTRUCTION SPECIHCATIONS L7 Industrial ❑ Open Bottom p Manteca Dia. of Well Excavation Dia. of Well Casin Z/' �F] Domestic/Private ❑ Gravel Pack "N Tracy Type of Casing_ }l sfG '� I']1 Publre `_ r r - je 90 Specifications t`l Other it Delta Depth of Grout Seal i - Type of Grou I I Irrigation 5_Approx. Depth I 1 Eastern Suifacs Seal Installed by Repair Work Done U Type,of Pump H.P. I State'Work Done_ Well Destruction ❑ Well,Diameter Sealing Material 4 Depth Depth hiller Material i Depth d TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOITION 13 DESTRUCTION I I {No septic system permitted it public sewer is 11 i available within 200 feet.) Installation will serve: Residence_ Commercial_ Other } Number of living units. ' Number of bedrooms Character of sod to a depth of 3 feet: I Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE L1 No. Ik Length of lines l! Total lengthtsize 11 t FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size IkR Number SUMPS Lt Distance to nearest: - Well Foundation Property Line . DISPOSAL PONDS_`_ O., 4 .:. " .. r , s .. .-,,•+.,,. 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's3signsture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shad not employ any person in such manner as to become subject to workman's compensation laws of California." CoMriclor's hiring or subcontracting signature certifi n the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion lawn nia." it - �f The app) nt mua cell for ail aqui ed in ct Complete drawing on reverse side. Ij Signed Title: - ` _ Date:' I m el_w�_ _ DEPARTMENT USE ONLY Application Accepted b -r L. D PP eP Y Date Area Pit or Grout Inspection by Date Final Inspection by__ Date Additional Comments: II k Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services I 445 N San Joaqufn,iP O Box 2009, Stkn, CA 95201 1} IC FEE NFO AMOUNT DUE AMOUNT REMITTED CA K RECEIVED BY GATE PERMIT NO. y . EN 134,IREV.I,r61 �/yr,(j.�j 4' f D