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APPLICATION FOR PERMIT u SAN 1QUIN COUNTY PUBLIC HEALTH S FICES pENVIRONMENTAL HEALTH DIVISIO,. P O BOX 2009 , SgN , CA 95201 ( 209 ) 468 - 3449 PERMIT EXPIREal; X YEAR COPY ( Compl in Triplicate ) Application is hereby sade , to San Joaquin County foo pe t to construct and/ or Install the vork herein described . This application is made in compliance with San JoaqAU3t1s.Eounty Ordinance No. 549 and 1862 and the Rules and Regulations of Sen Joaquin County Public Health Services . 66 IVI Job Address 7461 a+ �Hu ✓ Ce' W4V City Stogy k <oYl Lot Size/Acreage / l >` rX 1 ,25' Owner's Name t 1 . Address 3y50 L'7 / e 4vHEr ✓Jo Phone 242 5 3 9 - 0 , _ • Conhaclor K < < Address Sf. 1 License No . 54165 '15r Phone d 04 TYPE OF WELL / , NEW WELL Z _ - WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PU PINS7ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring .Well C7 DISTAINJ4NEA ST: SEPTIC TANK SEWER LINES DISPOSAL FLD . PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS / SUMPS _ - ,INTENDED USE TYPE OF WELL PF108LEM AREA CONSTRUCTION SPECIFICATIONS q do ❑ Industrial ❑ Open Bottom ❑ Manteca Ois . of Well Excavation Dia . of Well Casing U Domestic/ Private 0 Gravel Pack ❑ Tracy Type of Casing PVC Specifications 50e ° d fl Public 17 Other Cl Delta Depth of Grout Seal 451 Type of Grotut. f" rr✓ err* ❑ Imoation Ak Approx , Depth ❑ Eastern Surface Seal Installed by Erca / / •x Repair Work Done Ll Type of Pump H . P . State Work Done \ _ Well Destruction O Well Diameter Sealing Material a Depth _S Depth Filler Material a Depth r� TYPE OF SEPTIC WORK : NEW INSTALLATION D REPAIR / ADDITION 71 DESTRUCTION CI ( No septic system permitted if public sewer is t' ` available within 200 feet. ) Installation will serve: Residents — 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San J 1iE � ylslpances, state laws, and rules and regulations of the San Joaquin County s f��V1 11 Home owner or licensed agent' s signature certifies the following : " I certify that in the performance of the worl�eF n is issued, I shell not employ any person in such manner as to become subject to workman's compensation laws of California. " Con �(°f�Wr' s ring unit signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell ampldtl {Ydfiot�l s subjac114 workman's compensa- tion laws of California. " The applicant mutilit call for all required" spa, ions. Complete drawing on everse side. SANT JOAOUIN C06NTY PUBI C H ! ,F) i VI S Signed Title: & f //rl4Nta�VYRONNIENTAL 11/ J � b'atiiiLl ' �, {. . FOR DEPARTMENT USE ONLY Application Accepted by Date _ Area Pit or Grout Inspection by Date Final Inspection by Date . "7 Additional Comments: Applicant - Return all copies to : SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/ SERVICER- - - - - -"- - - " - '- "—'— 445 N SAN JOAQUIN , P O BOX 2009 , STOCXTON , CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CC NT VIED BY GATE PERMIT NO. • EH 13-24 irnll EH 4,26 // Tlawco S • �' ��pV3 � 1 QI �/ ^ /��