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APPLICATION FOR PERMIT SAN .,_AQUIN COUNTY PUBLIC- HEALTH L:},�VICES ENVIRONMENTAL HEARTH DIVISION r - 445 N SAN JOAQUIN, PHO E (209)468-3420 P 0 BOX 2009, STOCK Nr CA 95201 PERM . EXPIRE 1 R M DATE S (Complete is Triplicate) Apylication is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public HealthServices.See/rviices. I Job Address 244 Oer7 Xe6cALakc City &1141 Lot Size/Acreage ,5ZS ?-A,.4/Glt/'f ,.4 1l S'�iet f Owner's Name `�f 1rx^-.e /it C . Address AT+ A' 9 Z,Td 9Z4( Lir{�1•(R64 , r.A Z Cantractor,fe/rA_X��a d�`f ��`;' Address Aw�/�e Co�.�i+ia t S 42 License No. °Z PhonA-Pr >r2"745 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACE ENT 171 DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION 12SYSTEM R PAIR ❑ OIHERe Monitoring Well ❑ ee •• DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "� DISPOSAL FLD.2i.Et<z PROP7. LINE ter' FOUNDATION AGRICULTURE WELL r OTHER WELL s� PITS/SUMPS 't'A� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Mantecs Dia. of Well Excavation +Kt Dia. of Weil Casing AIA * Domestic/Private 0 Gravel Pack ❑ Tracy Type of Cas ng A►/1 Specifications I'I Public l4 Other 0"f oall f1 Delta Depth of Gr,wt Seal VA Type of Grou& Ir I Irrigation -9—JApprox. Depth I I Eastern Surface Sen Installed by wA-b4- Repair Work Done U Type of Pump H.P. State Work Hone_ Well Destruction ❑ Well Diameter Sealing Materiel) A Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted it public sewer is Ori 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: -91 depth SEPTIC TANK. ❑ Type/Mfg Capacitynts PKG. TREATMENT PLT.❑ REgf901aal Distance to nearest: Weil Foundation Pt 'r�y 04-1902-- RAIII 'AAA dim LEACHING LINE ❑ No. 6 Length of lines Tcm110 FILTER BED 0 Distance to nearest: Well Foundation - ENVIR� �E�t}�S (cN SEEPAGE PITS 11 Depth Sire Number SUMPS Li Distance to nearest: Well Foundati n Property Line DISPOSAL PONDS ❑ 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 Sen Joaquin County Home owner or licensed agent's iignaturs 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 such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signsture 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." The applicant7mt call for all required inspections. Complete drawing on� ireverse e. Signed X �� (rLe■�.ticv_ ' L TitleG ear o Date: /s11� 1`�3 FOR DEPARTiNg� Application Accepted by ENT USE ONLY Data dy/15 Area Pit or Grout Inspection by Date Final Inspection by _ Date Additional Comments, Applicant - Return all copies to: Sea Joaquin County Public Health Services �/ 1 Environmental Health Perm t/Services 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 INfO CK AMOUNT,OUE AMOUNT REMITTED CASH RECEIVED SY JDATE PERMIV NO. . t I EN 13.24111EV.ir„d2 ��' /4 7 G� '6Z� ,�J �'� OD�� f EN 14-M CCC�ii 6 r 1 r