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APPLICATION FOR PERMIT �j� _ SANQUIN COUNTY PUBLIC ffEALTfi 1y�F.S L� I ENVIRONMENTAL ILEALTH DIVIS (� 445 N SAN JOAQUiN, PHONE (209) 6t�Io / P O BOX 2009, STOCgTON, CA SFAC # ------ PERMIT EXPIRE YEAR FR 9 DAT /SS (Complete in TriplicateLINVT - I Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This'"1 application In made in compliance with San Joaquin County Ordinance No. $49 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �' 'TPInC V(^ Ci1Fyy —'"t"1"1 Lot Size/Acreage 1K/ Q 1oc h 1 il /klvAej-Ktf Owner's s Name 1 '�Sr�fVl- Address ZnJf S� �+.W^ 161[' FSS+ /�Q.'1t- gv(„wZ Phan. `LQ 9-33sr1 Contractor 1 FSE t^� Address1}sKbSf:2�F� �9)3�I License No. S�I 3 Phone 00391-8-/12- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 14onitorlag Well Ly DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial O Open Bottom ❑ Manteca Ore. of Well Excavatillon Dia. of Well Casing r (I Domestic/Private L) Gravel Pack C3 Tracy Type of Casing_ !No(( _ Specifications 11 Public (I Other n Delta Depth of Grout Seal /25 TypeoI Grou1 1 I Initiation _Approx. Depth I I Eastern Surface Soul Installed by �"t �✓a r Lie L1f.1„^4_ Repair Work Done ❑ Type of Pump H.P. Stele Work Done IF_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth 133 Tiller Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 lest.) Installation will serve: Residence _ Commercial _ Other Number of living unite _ Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest' Well Foundation Propeny Line LEACHING LINE ❑ No. & Length of Innes Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearasC Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Sen Joaquin County Mortal owner or licensed agent's signature cenifles the following: "1 candy that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as to become wbject to workmen's compensation taws of Calitomre." Contractor's hiring of sub-contracting signature canities the following: "I cartify,that in the performance of the work for which this permit is issued, I shall employ persons subject to workrtun's compena- tion laws of Californla." The applicant mus call f"l required inspection&. Complete drawing on reverse side. Signed Ti[le(Qe2a��,� rJGaK/C�/TJtoL Date: Zy ' / _ 7 FOR DEPARTMENT USE ONLY Application Accepted by �-h/Mt✓1'z{.a Date / Ll 1 LI Area .l) �Vlvt21 Pit or Grout inspection by Dale Final lJ�Inspection by �� - "I Dau I (tr Additional Corrrnu: m �� X Ac�/1�+ (✓ � ,�t%:GPhi/7Y>",P�(.�cd Applicant - Return all copies to: San Joaquin Cou ty Public Health Services ` Environmental Health Permit/Services 445 N San Joaquin Box 2009, Stkn, GA 95201 L,(fl�/5J�5 I INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT-NO. • ER 17"111REV.irnl)Em 14 X OU D �/ '24-