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APPLICATION FOR PERU I 1 S# c9 'A SAN JOAQUIN COUNTY PUBLIC HEALTH S 6}�IS ENVIRONMMTAL HEALTH DIVIS 445 N SAN JOAQUIN, PHONES (209)413 P O BOX 2009, STOCSTON, CA 9MW 0 2�MIT WIRES- YBO JDATEIIINM ERQM— (Complete in Triplicate) Application is hereby made to ran Joaquin County for a permit to construct and/or install the work herein described. This application is mme in ecepliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health services, Job Address'?Y ,S,, 7 �cra^tC'i T� - �✓�� City M- 81 Lot bi se/Acreage Owner's Name o-v'-O LLS Address•Z L/10 _Cu.IMl✓ n_ RCLNtO K. SG.W }tic "WhAona .SLID r 2 - t1j, Contractus' s E r:'v' Address PO v -94M K-'- t-V,l C License NoCs`7—D7-D7Phone7�' S� TYPE OF WELLIPUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well L7 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OyT:Ep Monitoring Well ❑ s5 yy DISTANCE TO NEAREST SEPTIC TANK SEWER LINES X±-='4 t DISPOSAL FL6 U� P OP LIkE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial ❑ Open Bottom ❑ Manteca Dra of Well Excavation Dia of Well Casing C) Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications I I Public n Other I1 pelts Depth of Grout Sea$ Type of Grout I I IrWalwn _Approx Depth 1 I Eastern Surface Seat Installed by _.. Repair Work Done U Type of Pump H P State Work Done S,.;/ .s- Wall Destruction O Well Diameter S Sealing Material A Depth f?ea,7- Q-Lg-o.aT fr+a►k..O -r-,c, ,S'b Depth Tiller Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I I fNo septic system permitted if public sewer Is available within 200 feet I Installation will serve Residence_ Commercial_ Other Number of Irving units Number of bedrooms Chsractsr of Soli to a depth of 3 fest Water table depth SEPTIC TANK 0 Type/Mfg Capacrty LNp��mpsrtmenIs PKG TREATMENT PLT D FIEN�etth� of Orsposal Distance to nearest Well Foundation� _�ropelt IQ r`l l'1� 7 I "lin! LEACHING LINE ❑ No b Length of lines SAN vAifi iRnnihii M J FILTER BED ❑ Distance to nearest Well Found Lf(, 11 `1Rropy(txyLrM, _ t + IJly1 f SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby csnify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances state taws, and rules and regulations of the San Joaquin County Home owner or licensed spent a signature oenifPat the following I certify that in the 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 compensation 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 scull employ persona subject to workman a compenu tion laws of California ' The applicant must call lot Ml�ired inspeewns Complete drawing on reverse side Signed X Title An, c�c-� o-z/ C 7 Date EPARTMENT USE �ONLY T Application Accepted by Date r Area U Pit or Grout Inspection raya:jA2 date Final Inspection by Date additional Comments Applicant - Return all copier, to San Joaquin County Public Ilealth Services RC.I.CIVCLJ 1 'rtl j �4 Eovirownental Ilealth Permit/Services 445 N San Joaquin, P 0 Box 2008, Stkn, CA 95201 EEE ,.c INFO AMOUNT DuE AMOUNT REMITTED CK ASSIH RECEIVED BY DATE PERMIT NO _ c CC2 . EM 1324 IRE1l 1'r r g z7)7 0 4P'I i 29 19_'z�2 EM 14M I V