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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTVSERVICES ' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 coutpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County/ Public Health Services. Job Address �Qr¢ WKt �ec,o -Vf6ie lL �tn City r 4n Lot Size/Acreage Q 4� c 1 Owner's Name 2 1 ✓1�2M?�/'^ Address_32-7 L'OSS6m VI-ler-Z, {R.tgby7 phone. ZO��J��'3�58 4400 o tstr ct Blvd.' C-5Y Contractor. �' _ - Q� V1�Y'V�Address�'Ei0.1�CV'S i t�tc.r �f1 L/.3-�j��r"License No. zZ53�9Z�- phony 05 83 ILYJ TYPE OF WELL/PUMP' NEW WELL ❑ - `WELL AGEMENT Ci DESTRUCTION ❑ Out of 3crvincgg Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E S -MonoKtdG N� DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES �Ur DISPOSAL FLO. PROP. LINE, 50 FOUNDATION Za AGRICULTURE WELL OTHER WELL IOOwds. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑-industrial -_O-Open-Bottom=-'-❑-Manteca7----" Dia--of-Well Excavation""`=-- --- "-Dia: of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications — ('I Public /' Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation 5Y Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth 5btt..eV1U,)6S Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 f 3 feet: Water table depth SEPTIC TANK ❑ T Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ N . & Length of lines Total length/size FILTER BED ❑ Dist a to nearest: Well Foundation Property Line SEEPAGE PITS I pth Size Number SUMPS LI Dist ce to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby Certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not > - employ any person-in sucn'mannlr asto become subject to workman's compensation laws of California:-Contractor's'niring'or suo-contracting`sigitature" 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." /J The applican ust call for all re re /dapections. Complete drawing on reverse side. r7 `_o / -7122-1-13 Signori � Title: f36�uT Fe'��I�tAn1,U.c �✓iCE Date: FOR DEPARTMENT USE ONLY Application Accepted by �1 f1'� Date :1•27 ''i3 Area u'lL-V-11� Pit or Grout Inspection by Date Finef•htiug.8',-ft rr- _ 1' �I c'..^w•D'taattee��11.1 Additional Comments: 350tk Etorlkn6 -5rAbnLty nf4yi (mat t Qat rhMU a(O f, CtY10.1y� b� CA 045 CEk-fkfi0* Applicant - Return all copies to: San Joaquin County Public Health services tam " Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT aREMITTED ZHRCEIVEDdy DATEEH tz.m IREV.Iix 5iWM LI II 1 I T"�'T' l✓ �`{X�