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APPLICATION SAN JOIN COUNTY P€TBL1'11Q ,HEALTH SLICES 1i ENVIRONMENTAL SSALTH DIVISION LOP PHONE (209)468-3420 pit STOCSTON, CA SUM PERMIT EXPIRESY YEAR ERQX_DATESUED (Complete in Triplicate) '! Application is hereby made to San Joaquin County for a permit to construct and/or installkthe xark here�n d s� t This application is made !n Corspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rule, and Regulations of San Joaquin County Public Health Services 0440 i�x5rh fvt y-0 .v+0, II Job Address 21; —1J��Ct IIIPJ City � kLot Size/Acreage I Owner's Name 0 IA4 ilb Q h 6111 Address aa j/1&Sbr! 1 y'14� RPhone - - 070 e�Sy Contractor kfAZAM. it Address License No. Phare TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION 0 Out of Service Well. ❑ PUMP INSTAI.i TION u SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well K DISTANCE TO NEAREST: SEPTIC TANK 11 SEWER LINES ��_ DISPOSAL FLO. a PROP. LINE _J FOUNDATION 11 IL5__ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom! ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing n Domestic/Private PLGfavell Pack ❑ Tracy Type of Casing__p)Z[. Specifications SE& *0 eve- 1'1 Public n Other 171 Delta Depth of Grout Seal Edi I1- Type of Grout I I Irrigation .1,Fl`pprox. Depth t 1 Eastern Surface Seal Installed by !`_G1-_ Repair Work Done 0 Type of Pump .. H.P. State Work Done Well Destruction ❑ Well Diameter ��- Sealing Material i Depth Depth .0 Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION f I REPAIRrADOITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ �' !I' Method of Disposal Distance to nearest: Well Foundation Property Lina I� LEACHING LINE ❑ No. b Length'hof lines Total length/size u F FILTER aED ❑ Distance to nearest. Well Founaanon Property Line !I SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest. Well Foundation Property Line DISPOSAL PONDS ❑ �1 I 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 Nome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies 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 laws of California." 11. I The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: J Date: 002? A.Aill"o FOR DEPARTMENT USE ONLY Application Accepted by Date T_ e Area ObEx_ I r Pit or Grout Inspection by Date Final Ilnapect clan by Date Additional Comments: + �„f` '[ {_ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE )NFO AMOUNT DUE �` AMOUNT REMITTED CCK if RECEIVED BY DATE PERMIT, PERMIT No. E>t 1124 taE<r.ri.si �- �!. � 0� 6� �L �l 7 d Ex,bb,