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APPLICATION FOR PERMIT SAN .16AQUIN COUNTY PUBLIC HEALTH 5`ARV I CES ENVIRONMENTAL HEA ,TH DIVISION 445 N SAN JOAQUIN, PH E (209)468-3420 P O BOX 2009, S IN, CA 95201 PERMIT EXPIRES M DATE (Complete in Tr 'pliCate) Application is hereby made to San Joaquin County for a permit to cc struct and/or install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 end the Rules and Regulations of San Joaquin County Public Health Services. Job Address 2,448 w' KL�{cw.wti Lame City I- Lot Size/Acreage l crc Owner's Name U l+ra`Afto-� IAC-. Address 515 W. T ri't . 4--4,4 CA 1-1�30Phone Zn5 8Z-OZ41 r 1 f/ 3�r Contracts 7U�rled Fx�le�i�Frol�s Address V-0-4f" C.e+.!*- CA A License No. LdZ}Za Phon w -745:4 TYPE TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACE AENT ❑ DESTRUCTION S Out of Service Veli ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Veli ❑ 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 — 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications —e- I1 Public Cl Other- Fl Delta Depth of Grout Seal Type of Grout I I Irrigation ._,_.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U AW-2* ^Q 9 H.P. State Work Qono We#.2LDasonflion M Well Diameter x •� 8ealing Pfaterial i Depth A/@.�Ce,+tcKf�_ S°/a u. n�vti ^Ito 1 Mw-1O�«.t NW'ZS Depth 3 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer isi available within 200 feet.! Installation will serve: Residence Commercial____„ Other Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Ca ity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundatio Ptopeny Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line 7 SEEPAGE PITS I t Depth Size Number r SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 Home owner or licensed agent's signature certifies the following: "I certify that in thi i performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensatior 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 per M is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must/call for ail required inswtions. Complete drawing on reverse sic a. Signed X �cril t C.r ..c lv Tiile: �4�5/g4 1 ,&/f r/ / G //x.. / Date. r R eibM�.[h A r� `/a� FOR DEPARTMENT USE ONLY P Application Accepted by Date C� I/a Area / �C Pit or Grout Inspection by Date Final nspection by •✓ Date Additional Comments: �fr,J � rl� A iCr , r Applicant - Return all copies to. San Joaquin County Public Health Services � .f�•� Environmental Health Permit/Services / 445 N San Joactuin, P 0 Box 2009, Stkn, CA 95201 �J Q . FEE AMOUNT DUE AMOUNT REMITTED CK Al RECEIVED BY DATE PERMIT'NO.O.INFO CASH EN >~z,ut¢v.rr 00 IN tbZ; y��